1. Abdominal aortic aneurysm (AAA) repair volume (IQI 4). HHS Division: Agency for Healthcare Research & Quality (AHRQ) Topic or Condition: Cardiovascular Sub-Topic or Sub-Condition: Cardiovascular Surgery Domain: Structure/Access Care Setting: Hospital Inpatient Numerator: Discharges, age 18 years and older, with an ICD-9-CM procedure code of 3834, 3844, 3864 or 3971 with an ICD-9-CM diagnosis code of AAA (4413) in any field Denominator: Not applicable Explanation If No Numerator/Denominator: Procedure Volume Indicator Data Source: Healthcare Cost and Utilization Project Purpose: Quality improvement; National tracking and trending; Comparative reporting Reported: Reported in both NHQR and NHDR. Appears in NHQR and NHDR Tables Appendices. Measure Maintenance: Annual HHS Measure Status: This HHS measure was originally submitted by the Agency for Healthcare Research and Quality (AHRQ) in 2008. This HHS measure was revised by AHRQ on October 27, 2010. Public Availability: Yes Related NQMC Measure(s): - Abdominal aortic aneurysm (AAA) repair: volume. 2. Abdominal aortic artery (AAA) repair mortality rate (IQI 11). HHS Division: Agency for Healthcare Research & Quality (AHRQ) Topic or Condition: Cardiovascular Sub-Topic or Sub-Condition: Cardiovascular Surgery Domain: Outcome Care Setting: Hospital Inpatient Numerator: Number of deaths (DISP=20) among cases meeting the inclusion and exclusion rules for the denominator Denominator: Discharges, age 18 years and older, with an ICD-9-CM code of 3834, 3844, 3864, or 3971 and an ICD-9-CM diagnosis code of AAA (4413) in any field Explanation If No Numerator/Denominator: NA Data Source: Healthcare Cost and Utilization Project Purpose: Quality improvement; National tracking and trending; Comparative reporting Reported: Reported in both NHQR and NHDR. Appears in NHQR and NHDR Tables Appendices. Measure Maintenance: Annual HHS Measure Status: This HHS measure was originally submitted by the Agency for Healthcare Research and Quality (AHRQ) in 2008. This HHS measure was revised by AHRQ on October 27, 2010. Public Availability: Yes Related NQMC Measure(s): - Abdominal aortic aneurysm (AAA) repair: mortality rate. 3. Accidental puncture or laceration (PDI 1). HHS Division: Agency for Healthcare Research & Quality (AHRQ) Topic or Condition: Patient Safety Sub-Topic or Sub-Condition: Complications Domain: Outcome Care Setting: Hospital Inpatient Numerator: Discharges among cases meeting the inclusion and exclusion rules for the denominator with an ICD-9-CM code denoting accidental cut, puncture, perforation or laceration during a procedure in any secondary diagnosis field Denominator: All surgical and medical discharges under age 18 defined by specific DRGs or MS-DRGs Explanation If No Numerator/Denominator: NA Data Source: Healthcare Cost and Utilization Project Purpose: Quality improvement; National tracking and trending; Comparative reporting Reported: Reported in both NHQR and NHDR. Appears in NHQR and NHDR Tables Appendices. Measure Maintenance: Annual HHS Measure Status: This HHS measure was originally submitted by the Agency for Healthcare Research and Quality (AHRQ) in 2008. This HHS measure was revised by AHRQ on October 27, 2010. Public Availability: Yes Related NQMC Measure(s): - Accidental puncture or laceration: rate per 1,000 eligible discharges. 4. Accidental puncture or laceration (PSI 15). HHS Division: Agency for Healthcare Research & Quality (AHRQ) Topic or Condition: Patient Safety Sub-Topic or Sub-Condition: Complications Domain: Outcome Care Setting: Hospital Inpatient Numerator: Discharges among cases meeting the inclusion and exclusion rules for the denominator with an ICD-9-CM code denoting accidental cut, puncture, perforation or laceration during a procedure in any secondary diagnosis field Denominator: All surgical and medical discharges age 18 years and older defined by specific DRGs or MS-DRGs Explanation If No Numerator/Denominator: NA Data Source: Healthcare Cost and Utilization Project Purpose: Quality improvement; National tracking and trending; Comparative reporting Reported: Reported in both NHQR and NHDR. Appears in NHQR and NHDR Tables Appendices. Measure Maintenance: Annual HHS Measure Status: This HHS measure was originally submitted by the Agency for Healthcare Research and Quality (AHRQ) in 2008. This HHS measure was revised by AHRQ on October 27, 2010. Public Availability: Yes Related NQMC Measure(s): - Accidental puncture or laceration (provider-level): rate per 1,000 discharges. 5. Accidental puncture or laceration (PSI 25). HHS Division: Agency for Healthcare Research & Quality (AHRQ) Topic or Condition: Patient Safety Sub-Topic or Sub-Condition: Complications Domain: Outcome Care Setting: Hospital Inpatient Numerator: Discharges among cases meeting the inclusion and exclusion rules for the denominator with an ICD-9-CM code denoting accidental cut, puncture, perforation or laceration during a procedure in any diagnosis field Denominator: All surgical and medical discharges age 18 years and older defined by specific DRGs or MS-DRGs Explanation If No Numerator/Denominator: NA Data Source: Healthcare Cost and Utilization Project Purpose: Area level/National tracking and trending Reported: Appears in NHQR and NHDR Tables Appendices. Measure Maintenance: Annual HHS Measure Status: This HHS measure was submitted by Agency for Healthcare Research and Quality (AHRQ) on October 27, 2010. Public Availability: Yes Related NQMC Measure(s): - Accidental puncture or laceration (area-level): rate per 100,000 population. 6. Acute myocardial infarction (AMI) mortality rate (IQI 15). HHS Division: Agency for Healthcare Research & Quality (AHRQ) Topic or Condition: Cardiovascular Sub-Topic or Sub-Condition: Acute Myocardial Infarction/Coronary Artery Disease Domain: Outcome Care Setting: Hospital Inpatient Numerator: Number of deaths (DISP=20) among cases meeting the inclusion and exclusion rules for the denominator Denominator: All discharges, age 18 years and older, with a principal diagnosis code of AMI Explanation If No Numerator/Denominator: NA Data Source: Healthcare Cost and Utilization Project Purpose: Quality improvement; National tracking and trending; Comparative reporting Reported: Discussed in National Healthcare Quality Report and National Healthcare Disparities Report accompanied by figures and tables. Appears in NHQR and NHDR Tables Appendices. Measure Maintenance: Annual HHS Measure Status: This HHS measure was originally submitted by the Agency for Healthcare Research and Quality (AHRQ) in 2008. This HHS measure was revised by AHRQ on October 27, 2010. Public Availability: Yes Related NQMC Measure(s): - Acute myocardial infarction (AMI): mortality rate. 7. Acute myocardial infarction (AMI) mortality rate, without transfer cases (IQI 32). HHS Division: Agency for Healthcare Research & Quality (AHRQ) Topic or Condition: Cardiovascular Sub-Topic or Sub-Condition: Acute Myocardial Infarction/Coronary Artery Disease Domain: Outcome Care Setting: Hospital Inpatient Numerator: Number of deaths (DISP=20) among cases meeting the inclusion and exclusion rules for the denominator Denominator: All discharges, age 18 years and older, with a principal diagnosis code of AMI excluding transfer from another hospital Explanation If No Numerator/Denominator: NA Data Source: Healthcare Cost and Utilization Project Purpose: Quality improvement; National tracking and trending; Comparative reporting Reported: Discussed in National Healthcare Quality Report and National Healthcare Disparities Report accompanied by figures and tables. Appears in NHQR and NHDR Tables Appendices. Measure Maintenance: Annual HHS Measure Status: This HHS measure was originally submitted by the Agency for Healthcare Research and Quality (AHRQ) in 2008. This HHS measure was revised by AHRQ on October 27, 2010. Public Availability: Yes Related NQMC Measure(s): - Acute myocardial infarction (AMI): mortality rate, without transfer cases. 8. Acute stroke mortality rate (IQI 17). HHS Division: Agency for Healthcare Research & Quality (AHRQ) Topic or Condition: Cardiovascular Sub-Topic or Sub-Condition: Stroke Domain: Outcome Care Setting: Hospital Inpatient Numerator: Number of deaths (DISP=20) among cases meeting the inclusion and exclusion rules for the denominator Denominator: All discharges, age 18 years and older, with principal diagnosis code for stroke Explanation If No Numerator/Denominator: NA Data Source: Healthcare Cost and Utilization Project Purpose: Quality improvement; National tracking and trending; Comparative reporting Reported: Reported in both NHQR and NHDR. Appears in NHQR and NHDR Tables Appendices. Measure Maintenance: Annual HHS Measure Status: This HHS measure was originally submitted by the Agency for Healthcare Research and Quality (AHRQ) in 2008. This HHS measure was revised by AHRQ on October 27, 2010. Public Availability: Yes Related NQMC Measure(s): - Acute stroke: mortality rate. 9. Adult asthma admission rate (PQI 15). HHS Division: Agency for Healthcare Research & Quality (AHRQ) Topic or Condition: Respiratory Sub-Topic or Sub-Condition: Asthma Domain: Outcome Care Setting: Ambulatory Numerator: All non-maternal discharges of age 18 years and older with ICD-9-CM principal diagnosis code of asthma Denominator: Population in metro area or county, age 18 years and older Explanation If No Numerator/Denominator: NA Data Source: Healthcare Cost and Utilization Project Purpose: Identify potentially preventable admissions in an area; National tracking and trending Reported: Reported in both NHQR and NHDR. Appears in NHQR and NHDR Tables Appendices. Measure Maintenance: Annual HHS Measure Status: This HHS measure was originally submitted by the Agency for Healthcare Research and Quality (AHRQ) in 2008. This HHS measure was revised by AHRQ on October 27, 2010. Public Availability: Yes Related NQMC Measure(s): - Adult asthma: hospital admission rate. 10. Adult current smokers with a visit who received advice to quit smoking from a doctor in the last 12 months. HHS Division: Agency for Healthcare Research & Quality (AHRQ) Topic or Condition: Behavioral Health Sub-Topic or Sub-Condition: Tobacco Use Domain: Process Care Setting: Ambulatory Numerator: Subset of the denominator population who received advice to quit smoking Denominator: Adults age 18 and over who reported in the survey year that they currently smoke and had a routine check up in the past 12 months and answered the question "In the past 12 months did a doctor advise you to stop smoking?" Nonresponses and "Don't Know" responses were excluded. Explanation If No Numerator/Denominator: NA Data Source: Medical Expenditure Panel Survey Purpose: Reported in both NHQR and NHDR Reported: Discussed in National Healthcare Disparities Report accompanied by tables. Appears in NHQR and NHDR Tables Appendices. Measure Maintenance: Annual HHS Measure Status: This HHS measure was originally submitted by the Agency for Healthcare Research and Quality (AHRQ) in 2008. This HHS measure was verified as being current by AHRQ on November 2, 2010. Public Availability: Yes 11. Adult hospital patients who did not receive good communication about discharge information. HHS Division: Agency for Healthcare Research & Quality (AHRQ) Topic or Condition: Health Care Delivery Sub-Topic or Sub-Condition: Communication Domain: Process Care Setting: Hospital Inpatient Numerator: Subset of denominator who answered "No" to either question Denominator: Hospital patients age 18 and over discharged alive who had at least an overnight stay and no psychiatry-related diagnoses and who responded to the questions "During this hospital stay, did doctors, nurses or other hospital staff talk with you about whether you would have the help you needed when you left the hospital?" and "During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?" Explanation If No Numerator/Denominator: NA Data Source: CMS; HCAHPS Survey Purpose: Reported in both NHQR and NHDR Reported: Discussed in National Healthcare Quality Report accompanied by figures. Appears in NHQR and NHDR Tables Appendices. Measure Maintenance: Annual HHS Measure Status: This HHS measure was originally submitted by the Agency for Healthcare Research and Quality (AHRQ) in 2008. This HHS measure was revised by AHRQ on November 1, 2010. Public Availability: Yes Related NQMC Measure(s): - Hospital inpatients' experiences: percentage of adult inpatients who reported whether they were provided specific discharge information. 12. Adult hospital patients who sometimes or never had good communications about medications they received in the hospital. HHS Division: Agency for Healthcare Research & Quality (AHRQ) Topic or Condition: Health Care Delivery Sub-Topic or Sub-Condition: Communication Domain: Process Care Setting: Hospital Inpatient Numerator: Subset of denominator who responded "sometimes" or "never" to either of 2 survey questions: "Before giving you any new medicine, how often did hospital staff tell you what the medicine was for?" and "Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand?" Denominator: Hospital patients age 18 and over discharged alive who had at least an overnight stay and no psychiatry-related diagnoses and who responded "yes" to the question "During this hospital stay, were you given any medicine that you had not taken before?" Explanation If No Numerator/Denominator: NA Data Source: CMS; HCAHPS Survey Purpose: Reported in both NHQR and NHDR Reported: Discussed in National Healthcare Quality Report accompanied by figures. Appears in NHQR and NHDR Tables Appendices. Measure Maintenance: Annual HHS Measure Status: This HHS measure was originally submitted by the Agency for Healthcare Research and Quality (AHRQ) in 2008. This HHS measure was revised by AHRQ on November 1, 2010. Public Availability: Yes Related NQMC Measure(s): - Hospital inpatients' experiences: percentage of adult inpatients who reported how often the hospital staff communicated well about medications. 13. Adult hospital patients who sometimes or never had good communications with doctors in the hospital. HHS Division: Agency for Healthcare Research & Quality (AHRQ) Topic or Condition: Health Care Delivery Sub-Topic or Sub-Condition: Communication Domain: Process Care Setting: Hospital Inpatient Numerator: Subset of denominator who responded "sometimes" or "never" to any of 3 survey questions: "During this hospital stay, how often did doctors treat you with courtesy and respect?", "During this hospital stay, how often did doctors listen carefully to you?" and "During this hospital stay, how often did doctors explain things in a way you could understand?" Denominator: Hospital patients age 18 and over discharged alive who had at least an overnight stay and no psychiatry-related diagnoses Explanation If No Numerator/Denominator: NA Data Source: CMS; HCAHPS Survey Purpose: Reported in both NHQR and NHDR Reported: Discussed in National Healthcare Quality Report accompanied by figures. Appears in NHQR and NHDR Tables Appendices. Measure Maintenance: Annual HHS Measure Status: This HHS measure was originally submitted by the Agency for Healthcare Research and Quality (AHRQ) in 2008. This HHS measure was revised by AHRQ on November 1, 2010. Public Availability: Yes Related NQMC Measure(s): - Hospital inpatients' experiences: percentage of adult inpatients who reported how often their doctors communicated well. 14. Adult hospital patients who sometimes or never had good communications with nurses in the hospital. HHS Division: Agency for Healthcare Research & Quality (AHRQ) Topic or Condition: Health Care Delivery Sub-Topic or Sub-Condition: Communication Domain: Process Care Setting: Hospital Inpatient Numerator: Subset of denominator who responded "sometimes" or "never" to any of 3 survey questions: "During this hospital stay, how often did nurses treat you with courtesy and respect?", "During this hospital stay, how often did nurses listen carefully to you?" and "During this hospital stay, how often did nurses explain things in a way you could understand?" Denominator: Hospital patients age 18 and over discharged alive who had at least an overnight stay and no psychiatry-related diagnoses Explanation If No Numerator/Denominator: NA Data Source: CMS; HCAHPS Survey Purpose: Reported in both NHQR and NHDR Reported: Discussed in National Healthcare Quality Report accompanied by figures. Appears in NHQR and NHDR Tables Appendices. Measure Maintenance: Annual HHS Measure Status: This HHS measure was originally submitted by the Agency for Healthcare Research and Quality (AHRQ) in 2008. This HHS measure was revised by AHRQ on November 1, 2010. Public Availability: Yes Related NQMC Measure(s): - Hospital inpatients' experiences: percentage of adult inpatients who reported how often their nurses communicated well. 15. Adults age 40 and over with diagnosed diabetes who had their blood cholesterol checked in the last 2 years. HHS Division: Agency for Healthcare Research & Quality (AHRQ) Topic or Condition: Diabetes Domain: Process Care Setting: Ambulatory Numerator: U.S. civilian noninstitutionalized adults age 40 and older with diabetes who answered "Within the past year" or "Within the past 2 years" to the question Denominator: U.S. civilian noninstitutionalized adults age 40 and older with diabetes who answered the question "About how long has it been since you had your blood cholesterol checked by a doctor or other health professional?" Nonresponses and "Don't Know" responses were excluded. Explanation If No Numerator/Denominator: NA Data Source: Medical Expenditure Panel Survey Purpose: Reported in both NHQR and NHDR Reported: Appears in NHQR and NHDR Tables Appendices. Measure Maintenance: Annual HHS Measure Status: This HHS measure was originally submitted by the Agency for Healthcare Research and Quality (AHRQ) in 2008. This HHS measure was verified as being current by AHRQ on November 2, 2010. Public Availability: Yes 16. Adults age 40 and over with diagnosed diabetes who had their feet checked for sores or irritation in the calendar year. HHS Division: Agency for Healthcare Research & Quality (AHRQ) Topic or Condition: Diabetes Domain: Process Care Setting: Ambulatory Numerator: U.S. civilian noninstitutionalized adults age 40 and older with diabetes who had a foot examination 1 or more times in the survey year Denominator: U.S. civilian noninstitutionalized adults age 40 and older with diabetes who answered the question: "During [the survey year], how many times did a health professional check your feet for any sores or irritations?" Nonresponses and "Don't Know" responses were excluded. Explanation If No Numerator/Denominator: NA Data Source: Medical Expenditure Panel Survey Purpose: Reported in both NHQR and NHDR Reported: Appears in NHQR and NHDR Tables Appendices. Measure Maintenance: Annual HHS Measure Status: This HHS measure was originally submitted by the Agency for Healthcare Research and Quality (AHRQ) in 2008. This HHS measure was verified as being current by AHRQ on November 2, 2010. Public Availability: Yes 17. Adults age 40 and over with diagnosed diabetes who received a dilated eye examination in the calendar year. HHS Division: Agency for Healthcare Research & Quality (AHRQ) Topic or Condition: Diabetes Domain: Process Care Setting: Ambulatory Numerator: U.S. civilian noninstitutionalized adults age 40 and older with diabetes who indicated they had at least 1 retinal eye examination in target period (depending on panel) Denominator: U.S. civilian noninstitutionalized adults age 40 and older with diabetes who answered a question about eye examinations in the survey years (see Comments section for details). Nonresponses and "Don't Know" responses were excluded. Explanation If No Numerator/Denominator: NA Data Source: Medical Expenditure Panel Survey Purpose: Reported in both NHQR and NHDR Reported: Appears in NHQR and NHDR Tables Appendices. Measure Maintenance: Annual HHS Measure Status: This HHS measure was originally submitted by the Agency for Healthcare Research and Quality (AHRQ) in 2008. This HHS measure was verified as being current by AHRQ on November 2, 2010. Public Availability: Yes 18. Adults age 40 and over with diagnosed diabetes who received a flu shot in the last 12 months. HHS Division: Agency for Healthcare Research & Quality (AHRQ) Topic or Condition: Diabetes Domain: Process Care Setting: Ambulatory Numerator: U.S. civilian noninstitutionalized adults age 40 and older with diabetes who had an influenza immunization in the past year Denominator: U.S. civilian noninstitutionalized adults age 40 and older with diabetes who answered the question "How long since you had a flu shot?" Nonresponses and "Don't Know" responses were excluded. Explanation If No Numerator/Denominator: NA Data Source: Medical Expenditure Panel Survey Purpose: Reported in both NHQR and NHDR Reported: Appears in NHQR and NHDR Tables Appendices. Measure Maintenance: Annual HHS Measure Status: This HHS measure was originally submitted by the Agency for Healthcare Research and Quality (AHRQ) in 2008. This HHS measure was verified as being current by AHRQ on November 2, 2010. Public Availability: Yes 19. Adults age 40 and over with diagnosed diabetes who received a hemoglobin A1c measurement in the calendar year. HHS Division: Agency for Healthcare Research & Quality (AHRQ) Topic or Condition: Diabetes Domain: Process Care Setting: Ambulatory Numerator: U.S. civilian noninstitutionalized adults age 40 and older with diabetes who had a hemoglobin A1c test at least once in the survey year Denominator: U.S. civilian noninstitutionalized adults age 40 and older with diabetes who answered the Diabetes Care Survey (DCS) question: During the survey year, "How many times did a doctor, nurse, or other health professional check for glycosylated hemoglobin or 'hemoglobin A-one-C'?" Nonresponses and "Don't Know" responses were excluded Explanation If No Numerator/Denominator: NA Data Source: Medical Expenditure Panel Survey Purpose: Reported in both NHQR and NHDR Reported: Appears in NHQR and NHDR Tables Appendices. Measure Maintenance: Annual HHS Measure Status: This HHS measure was originally submitted by the Agency for Healthcare Research and Quality (AHRQ) in 2008. This HHS measure was verified as being current by AHRQ on November 2, 2010. Public Availability: Yes 20. Adults age 65 and over who received a prescription for a potentially inappropriate medication in the calendar year. HHS Division: Agency for Healthcare Research & Quality (AHRQ) Topic or Condition: Patient Safety Sub-Topic or Sub-Condition: Medication Management Domain: Process Care Setting: Ambulatory Numerator: Persons age 65 and over who had 1 or more of the 11 or 33 potentially inappropriate medications Denominator: U.S. population age 65 and over Explanation If No Numerator/Denominator: NA Data Source: Medical Expenditure Panel Survey Purpose: Reported in both NHQR and NHDR Reported: Discussed in National Healthcare Disparities Report accompanied by figures. Appears in NHQR and NHDR Tables Appendices. Measure Maintenance: Annual HHS Measure Status: This HHS measure was originally submitted by the Agency for Healthcare Research and Quality (AHRQ) in 2008. This HHS measure was verified as being current by AHRQ on November 2, 2010. Public Availability: Yes