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Inactive Measures

Hospital Risk-Standardized Complication Rate Following Implantation of ICD

INACTIVE REVIEW: This measure review is older than five years.

This measure provides hospital specific risk-standardized rates of procedural complications following the implantation of an ICD in patients at least 65 year of age. At present, the measure uses clinical data available in the National Cardiovascular Data Registry ICD registry for risk adjustment that has been linked with administrative claims data using direct and indirect patient identifiers to identify procedural complications

Date Reviewed: November 7, 2015

30-day, all-cause, risk-standardized mortality rate following Percutaneous Coronary Intervention for patients with ST segment elevation MI or cardiogenic shock

INACTIVE REVIEW: This measure review is older than five years.

This measure estimates hospital risk-standardized 30-day all-cause mortality rate following percutaneous coronary intervention among patients who are 18 years of age or older with STEMI or cardiogenic shock at the time of procedure. The measure uses clinical data available in the National Cardiovascular Data Registry CathPCI registry for risk adjustment. For the purpose of development, the measure cohort was derived in a Medicare FFS population of patients 65 years of age or older with a PCI. For the purpose of development and testing, the measure used a Medicare FFS population of patients 65 years of age or older with a PCI. However, the measure is designed to be used in the broader population of PCI patients

Date Reviewed: November 7, 2015

Adult Major Depressive Disorder: Coordination of Care of Patients with Specific Comorbid Conditions

INACTIVE REVIEW: This measure review is older than five years.

Percentage of medical records of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) and a specific diagnosed comorbid condition (diabetes, coronary artery disease, ischemic stroke, intracranial hemorrhage, chronic kidney disease [stages 4 or 5], End Stage Renal Disease [ESRD] or congestive heart failure) being treated by another clinician with communication to the clinician treating the comorbid condition.

Date Reviewed: November 19, 2017

Hepatitis C Ribonucleic Acid (RNA) Testing Before Initiating Treatment

INACTIVE REVIEW: This measure review is older than five years.

Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving antiviral treatment for whom quantitative HCV RNA testing was performed within 6 months prior to initiation of antiviral treatment (paired with NQF 0396)

Date Reviewed: July 26, 2014

Hospital 30-day, all-cause, risk standardized readmission rate following acute MI hospitalization

INACTIVE REVIEW: This measure review is older than five years.

The measure estimates a hospital-level 30-day risk-standardized readmission rate for patients discharged from the hospital with a principal diagnosis of acute MI. The outcome is defined as unplanned readmission for any cause within 30 days of the discharge date for the index admission. A specified set of planned readmissions do not count as readmissions. The target population is patients aged 18 years and older. CMS annually reports the measure for individuals who are 65 years and older and are either Medicare FFS beneficiaries hospitalized in non-federal hospitals or patients hospitalized in Department of VA facilities

Date Reviewed: November 7, 2015

Hospital 30-day, all cause, unplanned, risk-standardized readmission rate following CABG surgery

INACTIVE REVIEW: This measure review is older than five years.

The measure estimates a hospital-level risk-standardized readmission rate, defined as unplanned readmission for any cause within 30 days from the date of discharge of the index CABG procedure, for patients 18 years and older discharged from the hospital after undergoing a qualifying isolated CABG procedure. The measure was developed using Medicare FFS patients 65 years and older and was tested in all-payer patients 18 years and older. An index admission is the hospitalization for a qualifying isolated CABG procedure considered for the readmission outcome.

Date Reviewed: November 7, 2015

Stroke and Stroke Rehabilitation: Rehabilitation Services Ordered

INACTIVE REVIEW: This measure review is older than five years.

Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or intracranial hemorrhage for whom occupational, physical, or speech rehabilitation services were ordered at or prior to inpatient discharge OR documentation that no rehabilitation services are indicated at or prior to inpatient discharge

Date Reviewed: April 7, 2014

Hospital 30-day, all cause, risk-standardized mortality rate following acute MI hospitalization for patients 18 and older

INACTIVE REVIEW: This measure review is older than five years.

The measure estimates a hospital 30-day risk-standardized mortality rate. Mortality is defined as death for any cause within 30 days after the date of admission of the index admission, for patients 18 and older discharged from the hospital with a principal diagnosis of acute MI. CMS annually reports the measure for patients who are 65 years or older and are either enrolled in fee-for-service Medicare and hospitalized in non-federal hospitals or are hospitalized in VA facilities

Date Reviewed: November 7, 2015

Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate Following Coronary Artery Bypass Graft Surgery

INACTIVE REVIEW: This measure review is older than five years.

The measure estimates a hospital-level risk-standardized mortality rate for patients 18 years and older discharged from the hospital following a qualifying isolated CABG procedure. Mortality is defined as death from any cause within 30 days of the procedure date of an index CABG admission. The measure was developed using Medicare FFS patients 65 years and older and was tested in all-payer patients 18 years and older. An index admission is the hospitalization for a qualifying isolated CABG procedure considered for the readmission outcome.

Date Reviewed: November 7, 2015

Beta-Blocker Therapy (i.e., Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Succinate) for Left Ventricular Systolic Dysfunction (LVSD) Prescribed at Discharge

INACTIVE REVIEW: This measure review is older than five years.

Proportion of heart failure patients age18 and older with LVSD for whom beta-blocker therapy (i.e., bisoprolol, carvedilol, or sustained-release metoprolol succinate) is prescribed at discharge. For purposes of this measure, LVSD is defined as chart documentation of a left ventricular ejection fraction (LVEF) less than 40% or a narrative description of left ventricular systolic (LVS) function consistent with moderate or severe systolic dysfunction.

Date Reviewed: November 7, 2015

Chlamydia Screening and Follow-up

INACTIVE REVIEW: This measure review is older than five years.

The percentage of female adolescents 18 years of age who had a chlamydia screening test with proper follow-up

Date Reviewed: November 7, 2015

Primary Percutaneous Coronary Intervention within 90 minutes of hospital arrival

INACTIVE REVIEW: This measure review is older than five years.

Percentage of acute MI patients with ST-segment elevation or LBBB on the ECG closest to arrival time receiving primary percutaneous coronary artery intervention during the hospital stay with a time from hospital arrival to PCI of 90 minutes or less

Date Reviewed: November 7, 2015

Chronic Liver Disease: Hepatitis A Vaccination

INACTIVE REVIEW: This measure review is older than five years.

The percentage of adult patients with chronic liver disease who have received a hepatitis A vaccine.

Date Reviewed: November 7, 2015

ACEI or ARB Therapy for Left Ventricular Systolic Dysfunction-HF Patients

INACTIVE REVIEW: This measure review is older than five years.

Percent of HF patients with LVSD who are prescribed an ACEI or ARB at hospital discharge. For purposes of this measure, LVSD is defined as chart documentation of a LVEF less than 40% or a narrative description of left ventricular systolic function consistent with moderate or severe systolic dysfunction.

Date Reviewed: November 7, 2015

Total Cost of Care Population-Based PMPM Index (Cost/Resource use Measure)

INACTIVE REVIEW: This measure review is older than five years.

Total Cost of Care reflects a mix of complicated factors such as patient illness burden, service utilization and negotiated prices.

Total Cost Index (TCI) is a measure of a primary care provider's risk adjusted cost effectiveness at managing the population they care for. TCI includes all costs associated with treating members including professional, facility inpatient and outpatient, pharmacy, lab, radiology, ancillary and behavioral health services.

A Total Cost of Care Index when viewed together with a Resource Use measure provides a more complete picture of population based drivers of health care costs.

Date Reviewed: November 7, 2015

Adults with Diabetes Mellitus That Had a Serum Creatinine in the Last 12 Reported Months

INACTIVE REVIEW: This measure review is older than five years.

This measure identifies adults with diabetes mellitus that had a serum creatinine test in last 12 reported months

Date Reviewed: November 23, 2013

Use of Appropriate Medications for People with Asthma

INACTIVE REVIEW: This measure review is older than five years.

The percentage of patients 5-64 years of age during the measurement year who were identified as having persistent asthma and who were appropriately prescribed medication during the measurement year

Date Reviewed: July 26, 2015

Adult Kidney Disease: Patients on Erythropoiesis-Stimulating Agent-Hemoglobin Level > 12.0 g/dL

INACTIVE REVIEW: This measure review is older than five years.

Percentage of calendar months within a 12-month period during which a Hemoglobin is measured for patients aged 18 years and older with a diagnosis of advanced CKD (stage 4 or 5, not receiving RRT) or ESRD (who are on hemodialysis or peritoneal dialysis) who are also receiving ESA therapy and have a Hemoglobin Level > 12.0 g/dL

Date Reviewed: November 23, 2013

Post-Discharge Appointment for Heart Failure Patients

INACTIVE REVIEW: This measure review is older than five years.

Percentage of patients, regardless of age, discharged from an inpatient facility to ambulatory care or home health care with a principal discharge diagnosis of heart failure for whom a follow up appointment was scheduled and documented prior to discharge (as specified).

Date Reviewed: July 21, 2018

Stroke and Stroke Rehabilitation: Thrombolytic Therapy

INACTIVE REVIEW: This measure review is older than five years.

This measure captures the proportion of acute ischemic stroke patients who arrive at this hospital within 2 hours of time last known well for whom IV t-PA was initiated at this hospital within 3 hours of time last known well

Date Reviewed: April 7, 2014

Skilled Nursing Facility 30-Day All Cause Readmission

INACTIVE REVIEW: This measure review is older than five years.

This measure estimates the risk-standardized rate of all-cause, unplanned, hospital readmissions for patients who have been admitted to a Skilled Nursing Facility (SNF) (Medicare fee-for-service [FFS] beneficiaries) within 30 days of discharge from their prior proximal hospitalization. The prior proximal hospitalization is defined as an admission to an IPPS, CAH, or a psychiatric hospital. The measure is based on data for 12 months of SNF admissions.

A risk-adjusted readmission rate for each facility is calculated as follows:

  • Step 1: Calculate the standardized risk ratio of the predicted number of readmissions at the facility divided by the expected number of readmissions for the same patients if treated at the average facility. The magnitude of the risk-standardized ratio is the indicator of a facility's effects on readmission rates.
  • Step 2: The standardized risk ratio is then multiplied by the mean rate of readmission in the population (i.e., all Medicare FFS patients included in the measure) to generate the facility-level standardized readmission rate.

For this measure, readmissions that are usually for planned procedures are excluded. Please refer to the Appendix, Tables 1 - 5 for a list of planned procedures.

The measure specifications are designed to harmonize with CMS' hospital-wide readmission (HWR) measure to the greatest extent possible. The HWR (NQF #1789) estimates the hospital-level, risk-standardize rate of unplanned, all-cause readmissions within 30 days of a hospital discharge and uses the same 30-day risk window as the SNFRM.

Date Reviewed: November 7, 2015

Risk-Adjusted CABG Readmission Rate

INACTIVE REVIEW: This measure review is older than five years.

Risk adjusted percentage of Medicare FFS beneficiaries aged 65 and older who undergo isolated coronary artery bypass grafting and are discharged alive but have a subsequent acute care hospital inpatient admission within 30 days of the date of discharge from the CABG hospitalization.

Date Reviewed: November 7, 2015

Stroke and Stroke Rehabilitation: Screening for Dysphagia

INACTIVE REVIEW: This measure review is older than five years.

Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or intracranial hemorrhage who receive any food, fluids or medication by mouth (PO) for whom a dysphagia screening was performed prior to PO intake in accordance with a dysphagia screening tool approved by the institution in which the patient is receiving care

Date Reviewed: April 7, 2014

HIV/AIDS: HIV RNA Control After Six Months of Potent Antiretroviral Therapy

INACTIVE REVIEW: This measure review is older than five years.

Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS, who had at least two medical visits during the measurement year, with at least 90 days between each visit, who are receiving potent antiretroviral therapy, who have a viral load < 200 copies/mL after at least 6 months of potent antiretroviral therapy

Date Reviewed: July 26, 2014

Hospital Wide All Cause Readmission Measure

INACTIVE REVIEW: This measure review is older than five years.

The measure estimates a hospital-level risk-standardized readmission rate (RSRR) of unplanned, all-cause readmission after admission for any eligible condition within 30 days of hospital discharge. The measure reports a single summary risk-standardized readmission rate (RSRR), derived from the volume-weighted results of five different models, one for each of the following specialty cohorts based on groups of discharge condition categories or procedure categories: surgery/gynecology, general medicine, cardiorespiratory, cardiovascular, and neurology, each of which will be described in greater detail below. The measure also indicates the hospital-level standardized risk ratios (SRR) for each of these five specialty cohorts. The outcome is defined as unplanned readmission for any cause within 30 days of the discharge date for the index admission. Admissions for planned procedures that are not accompanied by an acute diagnosis do not count as readmissions in the measure outcome. The target population is patients 18 and over. CMS annually reports the measure for patients who are 65 years or older and are enrolled in fee-for-service (FFS) Medicare and hospitalized in non-federal hospitals.

Date Reviewed: November 7, 2015

Non-Diabetic Nephropathy - Use of ACE Inhibitor or ARB Therapy

INACTIVE REVIEW: This measure review is older than five years.

The percentage of patients aged 18 years and older with proteinuria who are taking an ACE inhibitor or ARB

Date Reviewed: November 23, 2013

Gap in HIV Medical Visits

INACTIVE REVIEW: This measure review is older than five years.

Percentage of patients, regardless of age, with a diagnosis of HIV who did not have a medical visit in the last 6 months of the measurement year. A medical visit is any visit in an outpatient/ambulatory care setting with a nurse practitioner, physician, and/or a physician assistant who provides comprehensive HIV care.

Date Reviewed: November 7, 2015

Asthma Medication Ratio

INACTIVE REVIEW: This measure review is older than five years.

The percentage of patients who have a medication ratio of controller medications to total asthma medications of 0.50 or greater during the measurement year.

Date Reviewed: July 26, 2015

Dementia: Counseling Regarding Risks of Driving

INACTIVE REVIEW: This measure review is older than five years.

Percentage of patients, regardless of age, with a diagnosis of dementia or their caregiver(s) who were counseled regarding the risks of driving and the alternatives to driving at least once within a 12 month period

Date Reviewed: April 7, 2014

HIV medical visit frequency

INACTIVE REVIEW: This measure review is older than five years.

Percentage of patients, regardless of age, with a diagnosis of HIV who had at least one medical visit in each 6-month period of the 24-month measurement period with a minimum of 60 days between medical visits. A medical visit is any visit in an outpatient/ambulatory care setting with a nurse practitioner, physician, and/or a physician assistant who provides comprehensive HIV care.

Date Reviewed: November 7, 2015

Heart Failure Admission Rate (PQI 8)

INACTIVE REVIEW: This measure review is older than five years.

Admissions with a principal diagnosis of heart failure per 100,000 populations, ages 18 years and older. Excludes cardiac procedure admissions, obstetric admissions, and transfers from other institutions. NOTE: The software provides the rate per population. However, common practice reports the measure as per 100,000 population. The user must multiply the rate obtained from the software by 100,000 to report admissions per 100,000.

Date Reviewed: November 7, 2015

Chronic Obstructive Pulmonary Disease (COPD) or Asthma in Older Adults Admission Rate (PQI 05)

INACTIVE REVIEW: This measure review is older than five years.

Admissions with a principal diagnosis of chronic obstructive pulmonary disease (COPD) or asthma per 100,000 population, ages 40 years and older. Excludes obstetric admissions and transfers from other institutions. (NOTE: The software provides the rate per population. However, common practice reports the measure as per 100,000 population. The user must multiply the rate obtained from the software by 100,000 to report admissions per 100,000 population)

Date Reviewed: July 26, 2015

Assessment and Classification of Disease Prognosis

INACTIVE REVIEW: This measure review is older than five years.

Percentage of patients 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease prognosis at least once within 12 months.

Date Reviewed: April 27, 2015

Annual cervical cancer screening or follow-up in high-risk women

INACTIVE REVIEW: This measure review is older than five years.

This measure identifies women age 12 to 65 diagnosed with cervical dysplasia (CIN 2), cervical carcinoma-in-situ, or HIV/AIDS prior to the measurement year, and who still have a cervix, who had a cervical CA screen during the measurement year.

Date Reviewed: November 7, 2015

Pharmacologic Therapy for Persistent Asthma

INACTIVE REVIEW: This measure review is older than five years.

Percentage of patient aged 5 through 64 years with a diagnosis of persistent asthma who were prescribed long-term control medication Three rates are reported for this measure:

  1. Patients prescribed inhaled corticosteroids (ICS) as their long term control medication
  2. Patients prescribed other alternative long term control medications (non-ICS)
  3. Total patients prescribed long-term control medication

Date Reviewed: July 26, 2015

Staging of Dementia

INACTIVE REVIEW: This measure review is older than five years.

Percentage of patients, regardless of age, with a diagnosis of dementia whose severity of dementia was classified as mild, moderate or severe at least once within a 12 month period

Date Reviewed: April 7, 2014

Rheumatoid Arthritis (RA): Disease-Modifying Anti-Rheumatic Drug (DMARD) Therapy

INACTIVE REVIEW: This measure review is older than five years.

Percentage of patients 18 years and older with a diagnosis of rheumatoid arthritis who are newly prescribed disease modifying anti-rheumatic drug therapy within 12 months.

Date Reviewed: April 27, 2015

Heart Failure: Left Ventricular Ejection Fraction Assessment (Outpatient Setting)

INACTIVE REVIEW: This measure review is older than five years.

Percentage of patients aged 18 years and older with a diagnosis of heart failure for whom the quantitative or qualitative results of a recent or prior (any time in the past) LVEF assessment is documented within a 12 month period

Date Reviewed: November 26, 2014

HIV/AIDS: CD4 Cell Count or Percentage Performed

INACTIVE REVIEW: This measure review is older than five years.

Percentage of patients aged six months and older with a diagnosis of HIV/AIDS, with at least two CD4 cell counts or percentages performed during the measurement year at least 3 months apart

Date Reviewed: July 26, 2014

Dementia: Screening for Depressive Symptoms

INACTIVE REVIEW: This measure review is older than five years.

Percentage of patients, regardless of age, with a diagnosis of dementia who were screened for depressive symptoms within a 12 month period

Date Reviewed: April 7, 2014

Rheumatoid Arthritis: Functional Status Assessment

INACTIVE REVIEW: This measure review is older than five years.

Percentage of patients 18 years and older with a diagnosis of rheumatoid arthritis for whom a functional status assessment was performed at least once during the measurement period.

Date Reviewed: April 27, 2015

Hospital 30-day, all-cause, risk-standardized mortality rate following heart failure hospitalization for patients 18 and older

INACTIVE REVIEW: This measure review is older than five years.

The measure estimates a hospital 30-day risk-standardized mortality rate. Mortality is defined as death for any cause within 30 days after the date of admission of the index admission, for patients 18 and older discharged from the hospital with a principal diagnosis of HF. CMS annually reports the measure for patients who are 65 years or older and are either enrolled in fee-for-service Medicare and hospitalized in non-federal hospitals or are hospitalized in VA facilities.

Date Reviewed: November 7, 2015

HIV/AIDS: Medical Visit

INACTIVE REVIEW: This measure review is older than five years.

Percentage of patients, regardless of age, with a diagnosis of HIV/AIDS, with at least two medical visits during the measurement year, with a minimum of 90 and 180 days between each visit

Date Reviewed: July 26, 2014

Rheumatoid Arthritis: Assessment of Disease Activity

INACTIVE REVIEW: This measure review is older than five years.

Percentage of patients 18 years and older with a diagnosis of rheumatoid arthritis (RA) and >=50% of total number of outpatient RA encounters in the measurement year with assessment of disease activity using a standardized measure.

Date Reviewed: April 27, 2015

Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Control (

INACTIVE REVIEW: This measure review is older than five years.

The percentage of members 18-75 years of age with diabetes (type 1 and type 2) whose most recent HbA1c level is <8.0% during the measurement year.

Date Reviewed: April 27, 2015

HIV/AIDS: Screening for High Risk Sexual Behaviors

INACTIVE REVIEW: This measure review is older than five years.

Percentage of patients, aged 13 years and older, who were screened for high risk sexual behaviors at least once within 12 months.

Date Reviewed: November 7, 2015

Rheumatoid Arthritis: Tuberculosis Screening

INACTIVE REVIEW: This measure review is older than five years.

Percentage of patients 18 years and older with a diagnosis of rheumatoid arthritis who have documentation of a tuberculosis (TB) screening performed within 12 months prior to receiving a first course of therapy using a biologic disease-modifying anti-rheumatic drug (DMARD).

Date Reviewed: April 27, 2015

Adult Major Depressive Disorder (MDD): Comprehensive Depression Evaluation: Diagnosis and Severity

INACTIVE REVIEW: This measure review is older than five years.

Percentage of patients aged 18 years and older with a diagnosis or recurrent episode of major depressive disorder (MDD) with evidence that they met the DSM-IV criteria for MDD AND for whom there is an assessment of depression severity during the visit in which a new diagnosis or recurrent episode was identified.

Date Reviewed: April 27, 2015

Hepatitis C: Counseling Regarding Risk of Alcohol Consumption

INACTIVE REVIEW: This measure review is older than five years.

Percentage of patients aged 18 years and older with a diagnosis of hepatitis C who were counseled regarding the risks of alcohol consumption at least once within the 12 month reporting period

Date Reviewed: July 26, 2014

Sleep Apnea: Positive Airway Pressure Therapy Prescribed

INACTIVE REVIEW: This measure review is older than five years.

Patients who were prescribed positive airway pressure therapy as a proportion of all patients aged 18 years and older with a diagnosis of moderate or severe obstructive sleep apnea

Date Reviewed: April 8, 2013

Hepatitis C: Hepatitis B Vaccination

INACTIVE REVIEW: This measure review is older than five years.

Percentage of patients aged 18 years and older with a diagnosis of hepatitis C who have received at least one injection of hepatitis B vaccine, or who have documented immunity to hepatitis B

Date Reviewed: July 26, 2014