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December 31, 2007

Physician Consortium for Performance Improvement®

Emergency medicine: percentage of patients aged 18 years and older with an emergency department discharge diagnosis of syncope who had a 12-lead ECG performed.

Emergency medicine: percentage of patients aged 18 years and older with the diagnosis of community-acquired bacterial pneumonia with an appropriate empiric antibiotic prescribed.

Emergency medicine: percentage of patients aged 18 years and older with the diagnosis of community-acquired bacterial pneumonia with mental status assessed.

Emergency medicine: percentage of patients aged 18 years and older with the diagnosis of community-acquired bacterial pneumonia with oxygen saturation documented and reviewed.

Emergency medicine: percentage of patients aged 18 years and older with the diagnosis of community-acquired bacterial pneumonia with vital signs documented and reviewed.

Emergency medicine: percentage of patients aged 40 years and older with an emergency department discharge diagnosis of non-traumatic chest pain who had a 12-lead ECG performed.

Emergency medicine: percentage of patients with an emergency department discharge diagnosis of AMI who had documentation of receiving aspirin within 24 hours before emergency department arrival or during emergency department stay.

December 24, 2007

Centers for Medicare & Medicaid Services

Acute myocardial infarction: percent of patients with documentation of low-density lipoprotein cholesterol (LDL-c) level in the hospital record or documentation that LDL-c testing was done during the hospital stay or is planned for after discharge. This updates a previously published measure summary.

Acute myocardial infarction: percent of patients with elevated low-density lipoprotein cholesterol (LDL-c greater than or equal to 100 mg/dL or narrative equivalent) who are prescribed a lipid-lowering medication at hospital discharge. This updates a previously published measure summary.

Centers for Medicare & Medicaid Services/The Joint Commission

Acute myocardial infarction: median time from hospital arrival to administration of fibrinolytic agent in patients with ST-segment elevation or LBBB on the ECG performed closest to hospital arrival time. This updates a previously published measure summary.

Acute myocardial infarction: median time from hospital arrival to PCI in patients with ST-segment elevation or LBBB on the ECG performed closest to hospital arrival time. This updates a previously published measure summary.

Acute myocardial infarction: percent of patients receiving fibrinolytic therapy during the hospital stay and having a time from hospital arrival to fibrinolysis of 30 minutes or less. This updates a previously published measure summary.

Acute myocardial infarction: percent of patients receiving PCI during the hospital stay with a time from hospital arrival to PCI of 90 minutes or less. This updates a previously published measure summary.

Acute myocardial infarction: percent of patients with a history of smoking cigarettes who receive smoking cessation advice or counseling during the hospital stay. This updates a previously published measure summary.

Acute myocardial infarction: percent of patients with LVSD and without both ACEI and ARB contraindications who are prescribed an ACEI or ARB at hospital discharge. This updates a previously published measure summary.

Acute myocardial infarction: percent of patients without aspirin contraindications who are prescribed aspirin at hospital discharge. This updates a previously published measure summary.

Acute myocardial infarction: percent of patients without aspirin contraindications who received aspirin within 24 hours before or after hospital arrival. This updates a previously published measure summary.

Acute myocardial infarction: percent of patients without beta-blocker contraindications who are prescribed a beta-blocker at hospital discharge. This updates a previously published measure summary.

Acute myocardial infarction: percent of patients without beta-blocker contraindications who received a beta-blocker within 24 hours after hospital arrival. This updates a previously published measure summary.

Joint Commission, The

Acute myocardial infarction: percent of patients who expired during hospital stay. This updates a previously published measure summary.

December 17, 2007

Physician Consortium for Performance Improvement®

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or TIA or intracranial hemorrhage undergoing CT or MRI of the brain within 24 hours of arrival at the hospital whose final report of the CT or MRI includes documentation of the presence or absence of each of the following: hemorrhage and mass lesion and acute infarction.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or TIA who were prescribed antiplatelet therapy at discharge.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or intracranial hemorrhage for whom consideration of rehabilitation services is documented.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or intracranial hemorrhage who received DVT prophylaxis by end of hospital day 2.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or intracranial hemorrhage who underwent a dysphagia screening process before taking any foods, fluids or medication by mouth.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or TIA whose final reports of the carotid imaging studies performed, with characterization of an internal carotid stenosis in the 30-99% range include reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke or TIA with documented permanent, persistent, or paroxysmal atrial fibrillation who were prescribed an anticoagulant at discharge.

Stroke and stroke rehabilitation: percentage of patients aged 18 years and older with the diagnosis of ischemic stroke whose time from symptom onset to arrival is less than 3 hours who were considered for tissue plasminogen activator (t-PA) administration.

State of Wisconsin, Department of Health and Family Services

Tobacco dependence treatment: percent of enrollees with a diagnosis of tobacco or nicotine addiction, tobacco use disorder, and/or a history of tobacco use, or self-identified smokers who had a pharmacological intervention only (MEDDIC-MS).

Tobacco dependence treatment: percent of enrollees with a diagnosis of tobacco or nicotine addiction, tobacco use disorder, and/or a history of tobacco use, or self-identified smokers who had at least one visit with a counseling and pharmacological intervention (MEDDIC-MS).

Tobacco dependence treatment: percent of enrollees with a diagnosis of tobacco or nicotine addiction, tobacco use disorder, and/or a history of tobacco use, or self-identified smokers who had at least one visit with a counseling intervention only (MEDDIC-MS).

Tobacco dependence treatment: percent of enrollees with a diagnosis of tobacco or nicotine addiction, tobacco use disorder, and/or a history of tobacco use, or self-identified smokers who had more than one visit and a counseling intervention only (MEDDIC-MS).

Tobacco dependence treatment: percent of enrollees with a diagnosis of tobacco or nicotine addiction, tobacco use disorder, and/or a history of tobacco use, or self-identified smokers who had more than one visit with a counseling and pharmacological intervention (MEDDIC-MS).

December 10, 2007

Centers for Medicare & Medicaid Services

Pneumonia: percent of immunocompetent patients with community-acquired pneumonia who receive an initial antibiotic regimen during the first 24 hours that is consistent with current guidelines. This updates a previously published measure summary.

Centers for Medicare & Medicaid Services/The Joint Commission

Pneumonia: percent of patients age 50 years and older, hospitalized during October, November, December, January, February, or March who were screened for influenza vaccine status and were vaccinated prior to discharge, if indicated. This updates a previously published measure summary.

Pneumonia: percent of patients aged 65 and older who were screened for pneumococcal vaccine status and were administered the vaccine prior to discharge, if indicated. This updates a previously published measure summary.

Pneumonia: percent of patients who had an assessment of arterial oxygenation by arterial blood gas measurement or pulse oximetry within 24 hours prior to or after arrival at the hospital. This updates a previously published measure summary.

Pneumonia: percent of patients who receive their first dose of antibiotics within 4 hours after arrival at the hospital. This updates a previously published measure summary.

Pneumonia: percent of patients who were transferred or admitted to the intensive care unit (ICU) within 24 hours of hospital arrival, who had blood cultures performed within 24 hours prior to or 24 hours after hospital arrival. This updates a previously published measure summary.

Pneumonia: percent of patients whose initial emergency department blood culture was performed prior to the administration of the first hospital dose of antibiotics. This updates a previously published measure summary.

Pneumonia: percent of patients with a history of smoking cigarettes who are given smoking cessation advice or counseling during hospital stay. This updates a previously published measure summary.

Joint Commission, The

Pneumonia: median time from arrival at the hospital to the administration of the first dose of antibiotic at the hospital. This updates a previously published measure summary.

Pneumonia: percent of immunocompetent intensive care unit (ICU) patients with community-acquired pneumonia who receive an initial antibiotic regimen during the first 24 hours that is consistent with current guidelines. This updates a previously published measure summary.

Pneumonia: percent of immunocompetent non-intensive care unit (ICU) patients with community-acquired pneumonia who receive an initial antibiotic regimen during the first 24 hours that is consistent with current guidelines. This updates a previously published measure summary.

Physician Consortium for Performance Improvement®

Hematology: percentage of patients aged 18 years and older with a diagnosis of chronic lymphocytic leukemia (CLL) who had baseline flow cytometry studies performed.

Hematology: percentage of patients aged 18 years and older with a diagnosis of multiple myeloma, not in remission, who were prescribed or received intravenous bisphosphonate therapy within the 12 month reporting period.

Hematology: percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) or an acute leukemia who had baseline cytogenetic testing performed on bone marrow.

Hematology: percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) who are receiving erythropoietin therapy with documentation of iron stores prior to initiating erythropoietin therapy.

December 3, 2007

Centers for Medicare & Medicaid Services/The Joint Commission

Surgical care improvement project: percent of cardiac surgery patients with controlled 6 A.M. postoperative blood glucose. This updates a previously published measure summary.

Surgical care improvement project: percent of colorectal surgery patients with immediate postoperative normothermia. This updates a previously published measure summary.

Surgical care improvement project: percent of patients who received prophylactic antibiotics consistent with current guidelines. This updates a previously published measure summary.

Surgical care improvement project: percent of patients who received prophylactic antibiotics within one hour prior to surgical incision. This updates a previously published measure summary.

Surgical care improvement project: percent of patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time. This updates a previously published measure summary.

Surgical care improvement project: percent of surgery patients on beta-blocker therapy prior to admission who received a beta-blocker during the perioperative period. This updates a previously published measure summary.

Surgical care improvement project: percent of surgery patients who received appropriate VTE prophylaxis within 24 hours prior to surgery to 24 hours after surgery. This updates a previously published measure summary.

Surgical care improvement project: percent of surgery patients with appropriate hair removal. This updates a previously published measure summary.

Surgical care improvement project: percent of surgery patients with recommended VTE prophylaxis ordered anytime from hospital arrival to 48 hours after Surgery End Time. This updates a previously published measure summary.

Physician Consortium for Performance Improvement®

Perioperative care: percentage of cardiac surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic antibiotics and who received a prophylactic antibiotic, who have an order for discontinuation of prophylactic antibiotics within 48 hours of surgical end time.

Perioperative care: percentage of non-cardiac surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic antibiotics and who received a prophylactic antibiotic, who have an order for discontinuation of prophylactic antibiotics within 24 hours of surgical end time.

Perioperative care: percentage of patients undergoing procedures for which VTE prophylaxis is indicated in all patients who had an order for low-molecular weight heparin (LMWH), low-dose unfractionated heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or 24 hours after surgery end time.

Perioperative care: percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first or second generation cephalosporin prophylactic antibiotic who had an order for cefazolin or cefuroxime for antimicrobial prophylaxis.

Perioperative care: percentage of surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic parenteral antibiotics who have an order for an antibiotic to be given within one hour (if fluoroquinolone or vancomycin, two hours) prior to the surgical incision (or start of procedure when no incision is required).

Perioperative care: percentage of surgical patients aged 18 years and older who have an order for a parenteral antibiotic to be given within one hour (if fluoroquinolone or vancomycin, two hours) prior to the surgical incision (or start of procedure when no incision is required) for whom administration of a prophylactic antibiotic has been initiated within one hour (if vancomycin, two hours) prior to the surgical incision (or start of procedure when no incision is required).

November 26, 2007

Australian Council on Healthcare Standards

Acute myocardial infarction (AMI): percentage of patients with an AMI requiring thrombolysis who receive thrombolytic therapy within 1 hour of presentation to the emergency department, as their primary treatment, during the 6 month time period.

Acute myocardial infarction (AMI): percentage of patients with an AMI who receive PTCA as their primary treatment and have balloon inflation within 1 hour of presentation to the emergency department, during the 6 month time period.

Waiting time: percentage of patients attending the emergency department allocated Australasian Triage Scale (ATS) Category 1 who are attended to immediately, during the 6 month time period.

Waiting time: percentage of patients attending the emergency department allocated Australasian Triage Scale (ATS) Category 2 who are attended to within 10 minutes, during the 6 month time period.

Waiting time: percentage of patients attending the emergency department allocated Australasian Triage Scale (ATS) Category 3 who are attended to within 30 minutes, during the 6 month time period.

Waiting time: percentage of patients attending the emergency department allocated Australasian Triage Scale (ATS) Category 4 who are attended to within 60 minutes, during the 6 month time period.

Waiting time: percentage of patients attending the emergency department allocated Australasian Triage Scale (ATS) Category 5 who are attended to within 120 minutes, during the 6 month time period.

Centers for Medicare & Medicaid Services/The Joint Commission

Heart failure: percent of patients discharged home with written instructions or educational material given to patient or caregiver at discharge or during the hospital stay addressing all of the following: activity level, diet, discharge medications, follow-up appointment, weight monitoring, and what to do if symptoms worsen. This updates a previously published measure summary.

Heart failure: percent of patients with a history of smoking cigarettes, who are given smoking cessation advice or counseling during hospital stay. This updates a previously published measure summary.

Heart failure: percent of patients with documentation in the hospital record that LVS function was evaluated before arrival, during hospitalization, or is planned for after discharge. This updates a previously published measure summary.

Heart failure: percent of patients with LVSD and without both ACEI and ARB contraindications who are prescribed an ACEI or ARB at hospital discharge. This updates a previously published measure summary.

Joint Commission, The

Pregnancy and related conditions: percent of live-born neonates who expire before the neonate becomes age 28 days. This updates a previously published measure summary.

Pregnancy and related conditions: percent of patients who have vaginal deliveries with third or fourth degree perineal laceration. This updates a previously published measure summary.

Pregnancy and related conditions: percent of patients with vaginal birth after cesarean section (VBAC). This updates a previously published measure summary.

November 19, 2007

Institute for Clinical Systems Improvement

Lipid management in adults: percentage of patients on a lipid lowering medication who have a fasting lipid panel every 3 to 12 months. This updates a previously published measure summary.

Lipid management in adults: percentage of patients with diagnosed coronary heart disease (CHD) or CHD equivalent who have had a diet evaluation. This updates a previously published measure summary.

Venous thromboembolism (VTE) prophylaxis: percentage of adult hospitalized patients who are assessed for VTE risk within 24 hours of admission. This updates a previously published measure summary.

Venous thromboembolism (VTE) prophylaxis: percentage of adult hospitalized patients who are assessed to be at risk for VTE who receive pharmacologic prophylaxis, unless contraindicated. This updates a previously published measure summary.

Venous thromboembolism (VTE) prophylaxis: percentage of hospitalized adult patients who require hospital readmission within 30 days of discharge for conditions related to VTE. This updates a previously published measure summary.

Physician Consortium for Performance Improvement®

Gastroesophageal reflux disease (GERD): percentage of patients aged 18 years and older seen for an initial evaluation of GERD who did not have a barium swallow test ordered.

Gastroesophageal reflux disease (GERD): percentage of patients aged 18 years and older seen for an initial evaluation of GERD with at least one alarm symptom who were either referred for upper endoscopy or had an upper endoscopy performed.

Gastroesophageal reflux disease (GERD): percentage of patients aged 18 years and older with a diagnosis of GERD or heartburn whose endoscopy report indicates a suspicion of Barrett's esophagus who had a forceps esophageal biopsy performed.

Gastroesophageal reflux disease (GERD): percentage of patients aged 18 years and older with diagnosis of GERD, seen for an initial evaluation, who were assessed for the presence or absence of the following alarm symptoms: involuntary weight loss, dysphagia, and GI bleeding.

Gastroesophageal reflux disease (GERD): percentage of patients aged 18 years and older with the diagnosis of GERD who have been prescribed chronic proton pump inhibitor (PPI) or histamine H₂ receptor antagonist (H₂RA) therapy who received an assessment of their GERD symptoms within 12 months.

Pediatric acute gastroenteritis: percentage of patients aged 1 month to 5 years of age with a diagnosis of acute gastroenteritis for whom an appropriate oral rehydration solution was recommended.

Pediatric acute gastroenteritis: percentage of patients aged 1 month to 5 years of age with a diagnosis of acute gastroenteritis who had documentation of hydration status.

Pediatric acute gastroenteritis: percentage of patients aged 1 month to 5 years of age with a diagnosis of acute gastroenteritis who had weight measurement recorded.

Pediatric acute gastroenteritis: percentage of patients aged 1 month to 5 years of age with a diagnosis of acute gastroenteritis whose parent/caregiver received education on diet and when to contact the physician.

November 12, 2007

Physician Consortium for Performance Improvement®

Community-acquired bacterial pneumonia: percentage of patients who had a documented rationale for level of care based on severity and safety of home care.

Community-acquired bacterial pneumonia: percentage of patients who received a smoking cessation intervention.

Community-acquired bacterial pneumonia: percentage of patients who were assessed for co-morbid conditions.

Community-acquired bacterial pneumonia: percentage of patients who were assessed for influenza immunization status.

Community-acquired bacterial pneumonia: percentage of patients who were assessed for pneumococcus immunization status.

Community-acquired bacterial pneumonia: percentage of patients who were prescribed an appropriate empiric antibiotic.

Community-acquired bacterial pneumonia: percentage of patients who were queried about smoking.

Community-acquired bacterial pneumonia: percentage of patients with a chest x-ray performed.

Community-acquired bacterial pneumonia: percentage of patients with hydration status assessed.

Community-acquired bacterial pneumonia: percentage of patients with mental status assessed.

Community-acquired bacterial pneumonia: percentage of patients with oxygen saturation assessed.

Community-acquired bacterial pneumonia: percentage of patients with vital signs recorded.

November 5, 2007

Child and Adolescent Health Measurement Initiative

Anticipatory guidance and parental education (AGPE) about development and behavior of the child from doctor(s) or other health provider(s): proportion of children whose parents had their informational needs met.

Anticipatory guidance and parental education (AGPE) about injury prevention from doctor(s) or other health provider(s): proportion of children whose parents had their informational needs met.

Anticipatory guidance and parental education (AGPE) about the physical care of the child from doctor(s) or other health provider(s): proportion of children whose parents had their informational needs met.

Anticipatory guidance and parental education (AGPE) from doctor(s) or other health provider(s): average percentage of recommended topics discussed by a child's doctor(s) or other health provider(s).

Anticipatory guidance and parental education (AGPE) from doctor(s) or other health provider(s): average percentage of topics for which parents had their informational needs met.

Anticipatory guidance and parental education (AGPE) from doctor(s) or other health provider(s): proportion of children whose health care provider(s) discussed at least 80% of the recommended AGPE topics.

Anticipatory guidance and parental education (AGPE) from doctor(s) or other health provider(s): proportion of children whose parents had their informational needs met on all recommended anticipatory guidance and parental education topics assessed.

Assessment of smoking, substance abuse, safety, and firearms risks in the family by a child's doctor(s) or other health care provider(s): proportion of children whose parents were assessed for one or more risk factors.

Assessment of smoking, substance abuse, safety, and firearms risks in the family: average percentage of recommended topics assessed.

Care coordination (CC): proportion of children needing more than one health care service who received coordinated care.

Family-centered care (FCC): average percentage of recommended aspects of family-centered care regularly received.

Family-centered care (FCC): proportion of children whose parents routinely received all aspects of family-centered care.

October 29, 2007

American Physical Therapy Association

Physical functional status: mean change score in patients' mobility following physical therapy intervention as assessed using the Outpatient Physical Therapy Improvement in Movement Assessment Log (OPTIMAL) Instrument.

Institute for Clinical Systems Improvement

Venous thromboembolism (VTE): percentage of adult patients receiving heparin therapy for VTE who have a baseline platelet count before starting heparin, and then a platelet count every other day for at least the first 3 days of therapy. This updates a previously published measure summary.

Venous thromboembolism (VTE): percentage of adult patients suspected of deep vein thrombosis (DVT) who have leg duplex ultrasound with compression performed despite a low clinical pretest probability and a negative D-dimer test. This updates a previously published measure summary.

Venous thromboembolism (VTE): percentage of adult patients treated for VTE who have been assessed for the need for graded compression stockings. This updates a previously published measure summary.

Venous thromboembolism (VTE): percentage of adult patients who have a high clinical pretest probability for pulmonary embolism (PE) who received low molecular weight heparin (LMWH) during evaluation. This updates a previously published measure summary.

Venous thromboembolism (VTE): percentage of low-molecular-weight heparin (LMWH)-eligible patients with deep vein thrombosis (DVT) treated in an outpatient setting. This updates a previously published measure summary.

Venous thromboembolism (VTE): percentage of patients diagnosed with VTE who meet the criteria for low-molecular-weight heparin (LMWH) and for whom LMWH is used. This updates a previously published measure summary.

October 22, 2007

Agency for Healthcare Research and Quality

Patients' experiences: percentage of adult primary care patients who reported how often it was easy for them to get appointments and needed care.

Patients' experiences: percentage of adult primary care patients who reported how often their doctor's office staff was courteous and helpful.

Patients' experiences: percentage of adult primary care patients who reported how often their doctors communicated well.

Patients' experiences: percentage of adult specialty care patients who reported how often it was easy for them to get appointments and needed care.

Patients' experiences: percentage of adult specialty care patients who reported how often their doctor's office staff was courteous and helpful.

Patients' experiences: percentage of adult specialty care patients who reported how often their doctors communicated well.

Patients' experiences: percentage of parents/guardians who reported how often it was easy for them to get appointments and needed care for their child.

Patients' experiences: percentage of parents/guardians who reported how often their child's doctor communicated well.

Patients' experiences: percentage of parents/guardians who reported how often their child's doctor's office staff was courteous and helpful.

Patients' satisfaction with care: adult primary care patient's overall rating of their doctor.

Patients' satisfaction with care: adult specialty care patient's overall rating of their doctor.

Patients' satisfaction with care: parent's/guardian's overall rating of their child's doctor.

October 15, 2007

Arthritis Foundation

Acetaminophen use: percentage of patients prescribed acetaminophen who have risk factors for liver disease AND the percentage of patients treated with high-dose (greater than or equal to 4 gm/day) acetaminophen who are advised of the associated risk of liver toxicity.

Cyclooxygenase 2 (COX-2)-selective non-steroidal anti-inflammatory drug (NSAID) use: percentage of patients treated with a COX-2-selective NSAID who are taking low-dose aspirin daily and have risk factors for GI bleeding who are treated concomitantly with either misoprostol or a proton pump inhibitor (PPI).

Low-dose aspirin use: percentage of patients treated with a low-dose aspirin daily who have 2 or more risk factors for GI bleeding who are treated concomitantly with either misoprostol or proton pump inhibitor (PPI).

Low-dose aspirin: percentage of patients prescribed low-dose aspirin (less than or equal to 325 mg/day) who are advised of the associated GI bleeding risks.

Non-selective non-steroidal anti-inflammatory drugs (NSAIDs): percentage of patients treated with a non-selective NSAID who have risk factors for GI bleeding and who are treated concomitantly with either misoprostol or a proton pump inhibitor (PPI).

Non-steroidal anti-inflammatory drug (NSAID) selection: percentage of patients who are NOT treated with a low-dose aspirin, have risk factors for GI bleeding and are prescribed an NSAID who receive either a non-selective NSAID plus a gastroprotective agent (proton pump inhibitor [PPI] or misoprostol) or a COX-2-selective NSAID.

Non-steroidal anti-inflammatory drug (NSAID) selection: percentage of patients who take coumadin and are prescribed an NSAID who receive either a cyclooxygenase 2 (COX-2)-selective NSAID or a nonacetylated salicylate.

Non-steroidal anti-inflammatory drugs (NSAIDs): percentage of patients prescribed an NSAID (non selective or selective) who are advised of the associated GI bleeding and renal risks with the GI risks documented.

Side effect monitoring practices for non-steroidal anti-inflammatory drugs (NSAIDs): percentage of patients treated with daily NSAIDs (selective or nonselective) with risk factors for developing renal insufficiency for whom serum creatinine is assessed at baseline and at least once in the first year following initiation of therapy.

Side effect monitoring practices for non-steroidal anti-inflammatory drugs (NSAIDs): percentage of patients treated with daily NSAIDs (selective or nonselective) with risk factors for GI bleeding for whom a complete blood count is performed at baseline and during the first year after initiating therapy.

October 8, 2007

Centers for Medicare & Medicaid Services/The Joint Commission

Surgical care improvement project: percent of cardiac surgery patients with controlled 6 A.M. postoperative blood glucose.

Surgical care improvement project: percent of colorectal surgery patients with immediate postoperative normothermia.

Surgical care improvement project: percent of patients who received prophylactic antibiotics consistent with current guidelines. This updates a previously published measure summary.

Surgical care improvement project: percent of patients who received prophylactic antibiotics within one hour prior to surgical incision. This updates a previously published measure summary.

Surgical care improvement project: percent of patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time. This updates a previously published measure summary.

Surgical care improvement project: percent of surgery patients on beta blocker therapy prior to admission who received a beta blocker during the perioperative period.

Surgical care improvement project: percent of surgery patients who received appropriate VTE prophylaxis within 24 hours prior to surgery to 24 hours after surgery.

Surgical care improvement project: percent of surgery patients with appropriate hair removal.

Surgical care improvement project: percent of surgery patients with recommended VTE prophylaxis ordered.

Institute for Clinical Systems Improvement

Diagnosis and management of attention deficit hyperactivity disorder (ADHD) in primary care for school age children and adolescents: percentage of patients diagnosed with ADHD whose medical record contains documentation that the clinician discussed the need for school-based supports and educational service options for children with ADHD. This updates a previously published measure summary.

Diagnosis and management of attention deficit hyperactivity disorder (ADHD) in primary care for school age children and adolescents: percentage of patients newly diagnosed with ADHD whose medical record contains documentation of DSM-IV or DSM-PC criteria being addressed. This updates a previously published measure summary.

Diagnosis and management of attention deficit hyperactivity disorder (ADHD) in primary care for school age children and adolescents: percentage of patients treated with medication for the diagnosis of ADHD whose medical record contains documentation of a follow-up visit twice a year. This updates a previously published measure summary.

Diagnosis and treatment of adult degenerative joint disease (DJD)/ Osteoarthritis (OA) of the knee: percentage of patients with DJD with documented education in four comprehensive areas: protecting the joint, exercise, pain relief, healthy living habits. This updates a previously published measure summary.

Diagnosis and treatment of adult degenerative joint disease (DJD)/Osteoarthritis (OA) of the knee: percentage of patients diagnosed with DJD with knee x-ray panels that include a standing view of the knee. This updates a previously published measure summary.

Diagnosis and treatment of headache: percentage migraineurs with treatment plans for mild, moderate, and severe headaches. This updates a previously published measure summary.

Diagnosis and treatment of headache: percentage of migraineurs with documented education. This updates a previously published measure summary.

October 1, 2007

Centers for Medicare & Medicaid Services

Acute myocardial infarction: percent of patients with documentation of low-density lipoprotein cholesterol (LDL-c) level in the hospital record or documentation that LDL-c testing was done during the hospital stay or is planned for after discharge. This updates a previously published measure summary.

Acute myocardial infarction: percent of patients with elevated low-density lipoprotein cholesterol (LDL-c greater than or equal to 130 mg/dL or narrative equivalent) who are prescribed a lipid-lowering medication at hospital discharge. This updates a previously published measure summary.

Centers for Medicare & Medicaid Services/The Joint Commission

Acute myocardial infarction: median time from hospital arrival to administration of fibrinolytic agent in patients with ST-segment elevation or left bundle branch block (LBBB) on the electrocardiogram (ECG) performed closest to hospital arrival time. This updates a previously published measure summary.

Acute myocardial infarction: median time from hospital arrival to percutaneous coronary intervention (PCI) in patients with ST-segment elevation or left bundle branch block (LBBB) on the electrocardiogram (ECG) performed closest to hospital arrival time. This updates a previously published measure summary.

Acute myocardial infarction: percent of patients receiving fibrinolytic therapy during the hospital stay and having a time from hospital arrival to fibrinolysis of 30 minutes or less. This updates a previously published measure summary.

Acute myocardial infarction: percent of patients receiving percutaneous coronary intervention (PCI) during the hospital stay with a time from hospital arrival to PCI of 90 minutes or less. This updates a previously published measure summary.

Acute myocardial infarction: percent of patients with a history of smoking cigarettes who receive smoking cessation advice or counseling during the hospital stay. This updates a previously published measure summary.

Acute myocardial infarction: percent of patients with left ventricular systolic dysfunction (LVSD) and without both angiotensin converting enzyme inhibitor (ACEI) and angiotensin receptor blocker (ARB) contraindications who are prescribed an ACEI or ARB at hospital discharge. This updates a previously published measure summary.

Acute myocardial infarction: percent of patients without aspirin contraindications who are prescribed aspirin at hospital discharge. This updates a previously published measure summary.

Acute myocardial infarction: percent of patients without aspirin contraindications who received aspirin within 24 hours before or after hospital arrival. This updates a previously published measure summary.

Acute myocardial infarction: percent of patients without beta blocker contraindications who are prescribed a beta blocker at hospital discharge. This updates a previously published measure summary.

Acute myocardial infarction: percent of patients without beta blocker contraindications who received a beta blocker within 24 hours after hospital arrival. This updates a previously published measure summary.

Joint Commission, The

Acute myocardial infarction: percent of patients who expired during hospital stay. This updates a previously published measure summary.

September 24, 2007

Agency for Healthcare Research and Quality

In-center hemodialysis patients' experiences: percentage of in-center hemodialysis patients who reported how often their nephrologist cared and communicated well.

In-center hemodialysis patients' experiences: percentage of in-center hemodialysis patients who reported how often they were satisfied with the quality of dialysis center care and operations.

In-center hemodialysis patients' experiences: percentage of in-center hemodialysis patients who reported whether specified information was provided to them.

In-center hemodialysis patients' satisfaction with care: in-center hemodialysis patients' overall ratings of their dialysis center staff.

In-center hemodialysis patients' satisfaction with care: in-center hemodialysis patients' overall ratings of their dialysis center.

In-center hemodialysis patients' satisfaction with care: in-center hemodialysis patients' overall ratings of their kidney doctors.

Institute for Clinical Systems Improvement

Major depression in adults in primary care: percentage of patients who have a depression follow-up contact within three months of initiating treatment. This updates a previously published measure summary.

Major depression in adults in primary care: percentage of patients whose results on 2 Patient Health Questionnaires (PHQ-9s) score less than 5 or similar testing (Hamilton Rating Scale for Depression score of 7 or less) within three to seven months after diagnosis. This updates a previously published measure summary.

Major depression in adults in primary care: percentage of patients whose results on 2 quantitative symptom assessment tools (such as Patient Health Questionnaire [PHQ-9]) decrease by 50 percent within three to seven months after diagnosis. This updates a previously published measure summary.

Major depression in adults in primary care: percentage of patients whose symptoms are reassessed by the use of a quantitative symptom assessment tool (such as Patient Health Questionnaire [PHQ-9]) within three months of initiating treatment. This updates a previously published measure summary.

Major depression in adults in primary care: percentage of patients with a new diagnosis of major depression, with documentation of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV TR) criteria within the three months prior to initial diagnosis. This updates a previously published measure summary.

Major depression in adults in primary care: percentage of patients with diabetes with documentation of screening for depression. This updates a previously published measure summary.

September 17, 2007

Press Ganey Associates, Inc.

Inpatient satisfaction: mean section score for "Admission" questions on Inpatient Survey. This updates a previously published measure summary.

Inpatient satisfaction: mean section score for "Discharge" questions on Inpatient Survey. This updates a previously published measure summary.

Inpatient satisfaction: mean section score for "Meals" questions on Inpatient Survey. This updates a previously published measure summary.

Inpatient satisfaction: mean section score for "Nurses" questions on Inpatient Survey. This updates a previously published measure summary.

Inpatient satisfaction: mean section score for "Overall Assessment" questions on Inpatient Survey. This updates a previously published measure summary.

Inpatient satisfaction: mean section score for "Personal Issues" questions on Inpatient Survey. This updates a previously published measure summary.

Inpatient satisfaction: mean section score for "Physician" questions on Inpatient Survey. This updates a previously published measure summary.

Inpatient satisfaction: mean section score for "Room" questions on Inpatient Survey. This updates a previously published measure summary.

Inpatient satisfaction: mean section score for "Tests and Treatments" questions on Inpatient Survey. This updates a previously published measure summary.

Inpatient satisfaction: mean section score for "Visitors and Family" questions on Inpatient Survey. This updates a previously published measure summary.

September 10, 2007

Agency for Healthcare Research and Quality

Accidental puncture or laceration (area-level): rate per 100,000 population. This updates a previously published measure summary.

Accidental puncture or laceration (provider-level): rate per 1,000 discharges. This updates a previously published measure summary.

Foreign body left during procedure (area level): discharges per 100,000 population. This updates a previously published measure summary.

Foreign body left during procedure (provider-level): rate per 1,000 discharges. This updates a previously published measure summary.

Iatrogenic pneumothorax (area-level): rate per 100,000 population. This updates a previously published measure summary.

Iatrogenic pneumothorax (provider-level): rate per 1,000 discharges. This updates a previously published measure summary.

Postoperative hemorrhage or hematoma requiring a procedure (area-level): rate per 100,000 population. This updates a previously published measure summary.

Postoperative hemorrhage or hematoma requiring a procedure (provider level): rate per 1,000 surgical discharges. This updates a previously published measure summary.

Postoperative wound dehiscence (area-level): rate of reclosure of post operative disruption of abdominal wall per 100,000 population. This updates a previously published measure summary.

Postoperative wound dehiscence (provider-level): rate of reclosure of postoperative disruption of abdominal wall per 1,000 cases of abdominopelvic surgery. This updates a previously published measure summary.

Selected infections due to medical care (area-level): rate per 100,000 population. This updates a previously published measure summary.

Selected infections due to medical care (provider-level): rate per 1,000 discharges. This updates a previously published measure summary.

Transfusion reaction (area-level): rate per 100,000 population. This updates a previously published measure summary.

Transfusion reaction (provider-level): rate per 1,000 discharges. This updates a previously published measure summary.

September 3, 2007

Agency for Healthcare Research and Quality

Birth trauma-injury to neonate: rate per 1,000 liveborn births. This updates a previously published measure summary.

Complications of anesthesia: rate per 1,000 surgery discharges with an operating room procedure. This updates a previously published measure summary.

Death in low-mortality DRGs: in-hospital deaths per 1,000 discharges. This updates a previously published measure summary.

Decubitus ulcer: rate per 1,000 discharges. This updates a previously published measure summary.

Failure to rescue: deaths per 1,000 discharges. This updates a previously published measure summary.

Obstetric trauma (3rd or 4th degree lacerations): rate per 1,000 Cesarean deliveries. This updates a previously published measure summary.

Obstetric trauma (3rd or 4th degree lacerations): rate per 1,000 instrument-assisted vaginal deliveries. This updates a previously published measure summary.

Obstetric trauma (3rd or 4th degree lacerations): rate per 1,000 vaginal deliveries without instrument assistance. This updates a previously published measure summary.

Postoperative hip fracture: rate per 1,000 surgical discharges. This updates a previously published measure summary.

Postoperative physiologic and metabolic derangement: rate per 1,000 elective surgical discharges with an operating room procedure. This updates a previously published measure summary.

Postoperative pulmonary embolism or deep vein thrombosis: rate per 1,000 surgical discharges with an operating room procedure. This updates a previously published measure summary.

Postoperative respiratory failure: rate per 1,000 elective surgical discharges with an operating room procedure. This updates a previously published measure summary.

Postoperative sepsis: rate per 1,000 elective surgery discharges with an operating room procedure and a length of stay of 4 days or more. This updates a previously published measure summary.

August 27, 2007

VHA, Inc.

Intensive care unit (ICU) palliative care: percent of 4-hour intervals (on Day Zero and Day One of ICU admission) for which pain was assessed and documented.

Intensive care unit (ICU) palliative care: percent of 4-hour intervals (on Day Zero and Day One of ICU admission) for which the documented pain score was less than or equal to 3.

Intensive care unit (ICU) palliative care: percent of patients who have documentation in the medical record that an interdisciplinary family meeting was conducted on or before Day Five of ICU admission.

Intensive care unit (ICU) palliative care: percent of patients who have documentation in the medical record that social work support was offered to the patient and/or family on or before Day Three of ICU admission.

Intensive care unit (ICU) palliative care: percent of patients who have documentation in the medical record that spiritual support was offered to the patient and/or family on or before Day Three of ICU admission.

Intensive care unit (ICU) palliative care: percent of patients who have documentation of advance directive status on or before Day One of the ICU admission.

Intensive care unit (ICU) palliative care: percent of patients who have documentation of ICU efforts to identify a health care proxy (or other appropriate surrogate decision-maker) on or before Day One of the ICU admission.

Intensive care unit (ICU) palliative care: percent of patients who have documentation of resuscitation status on or before Day One of ICU admission.

Intensive care unit (ICU) palliative care: percent of patients whose family was personally given a written information leaflet by an ICU team member on or before Day One of ICU admission.

Intensive care unit (ICU) palliative care: presence of room designated for meetings between clinicians and ICU families.

August 20, 2007

Agency for Healthcare Research and Quality

Cholecystitis/cholelithiasis: laparoscopic cholecystectomy rate. This updates a previously published measure summary.

Coronary artery disease: bilateral cardiac catheterization rate. This updates a previously published measure summary.

Coronary artery disease: coronary artery bypass graft (CABG) area rate. This updates a previously published measure summary.

Coronary artery disease: percutaneous transluminal coronary angioplasty (PTCA) area rate. This updates a previously published measure summary.

Hysterectomy: hysterectomy area rate. This updates a previously published measure summary.

Incidental appendectomy: incidental appendectomy among the elderly rate. This updates a previously published measure summary.

Laminectomy or spinal fusion: laminectomy or spinal fusion area rate. This updates a previously published measure summary.

Maternity care: Cesarean delivery rate. This updates a previously published measure summary.

Maternity care: primary Cesarean delivery rate. This updates a previously published measure summary.

Maternity care: vaginal birth after Cesarean (VBAC) rate, all. This updates a previously published measure summary.

Maternity care: vaginal birth after Cesarean (VBAC) rate, uncomplicated. This updates a previously published measure summary.

Wisconsin Collaborative for Healthcare Quality

Access: time to third next available appointment for a physical exam. This updates a previously published measure summary.

Access: time to third next available appointment for an office visit. This updates a previously published measure summary.

August 13, 2007

Agency for Healthcare Research and Quality

Abdominal aortic aneurysm (AAA) repair: mortality rate. This updates a previously published measure summary.

Abdominal aortic aneurysm (AAA) repair: volume. This updates a previously published measure summary.

Acute myocardial infarction (AMI): mortality rate, without transfer cases. This updates a previously published measure summary.

Acute myocardial infarction (AMI): mortality rate. This updates a previously published measure summary.

Acute stroke: mortality rate. This updates a previously published measure summary.

Carotid endarterectomy (CEA): mortality rate. This updates a previously published measure summary.

Carotid endarterectomy (CEA): volume. This updates a previously published measure summary.

Congestive heart failure (CHF): mortality rate. This updates a previously published measure summary.

Coronary artery bypass graft (CABG): volume. This updates a previously published measure summary.

Coronary artery disease: coronary artery bypass graft (CABG) mortality rate. This updates a previously published measure summary.

Craniotomy: mortality rate. This updates a previously published measure summary.

Esophageal cancer: esophageal resection mortality rate. This updates a previously published measure summary.

Esophageal resection: volume. This updates a previously published measure summary.

Gastrointestinal (GI) hemorrhage: mortality rate. This updates a previously published measure summary.

Hip fracture: mortality rate. This updates a previously published measure summary.

Hip osteoarthrosis: hip replacement mortality rate. This updates a previously published measure summary.

Pancreatic cancer: pancreatic resection mortality rate. This updates a previously published measure summary.

Pancreatic resection: volume. This updates a previously published measure summary.

Percutaneous transluminal coronary angioplasty (PTCA): mortality rate. This updates a previously published measure summary.

Percutaneous transluminal coronary angioplasty (PTCA): volume. This updates a previously published measure summary.

Pneumonia: mortality rate. This updates a previously published measure summary.

August 6, 2007

National Committee for Quality Assurance

Health plan members' experiences: percentage of parents or guardians of health plan members who reported how much of a problem they had in getting needed care for their child.

Health plan members' experiences: percentage of parents or guardians of health plan members who reported how much of a problem they had with getting prescription medicine for their children with chronic conditions.

Health plan members' experiences: percentage of parents or guardians of health plan members who reported how much of a problem they had with getting specialized services for their children with chronic conditions.

Health plan members' experiences: percentage of parents or guardians of health plan members who reported how much of a problem they had with health plan customer service for their child.

Health plan members' experiences: percentage of parents or guardians of health plan members who reported how often the medical office staff was courteous, respectful, and helpful.

Health plan members' experiences: percentage of parents or guardians of health plan members who reported how often their child got care quickly.

Health plan members' experiences: percentage of parents or guardians of health plan members who reported how often their child's doctors or other health providers communicated well.

Health plan members' experiences: percentage of parents or guardians of health plan members who reported how often their health plan handled their child's claims correctly and in a reasonable time.

Health plan members' experiences: percentage of parents or guardians of health plan members who reported their experiences in getting needed information for their children with chronic condition.

Health plan members' experiences: percentage of parents or guardians of health plan members who reported their experiences with shared decision-making for their children with chronic condition.

Health plan members' experiences: percentage of parents or guardians of health plan members who reported their experiences with the personal doctor or nurse of their children with chronic conditions.

Health plan members' experiences: percentage of parents or guardians of health plan members who reported they had assistance in coordinating care and services for their children with chronic conditions.

Health plan members' satisfaction with care: parents' or guardians' ratings of the specialist their child saw most often.

Health plan members' satisfaction with care: parents' or guardians' ratings of their child's health care.

Health plan members' satisfaction with care: parents' or guardians' ratings of their child's health plan.

Health plan members' satisfaction with care: parents' or guardians' ratings of their child's personal doctor.

July 30, 2007

National Committee for Quality Assurance

Health plan members' experiences: percentage of adult health plan members who reported how often it was easy to get needed care.

Health plan members' experiences: percentage of adult health plan members who reported how often their doctor and other health provider talked about specific things they could do to prevent illness.

Health plan members' experiences: percentage of adult health plan members who reported how often their doctors communicated well.

Health plan members' experiences: percentage of adult health plan members who reported how often their health plans handled their claims quickly and correctly.

Health plan members' experiences: percentage of adult health plan members who reported how often their personal doctor seemed informed and up-to-date about care they got from other doctors or other health providers.

Health plan members' experiences: percentage of adult health plan members who reported how often they get care quickly.

Health plan members' experiences: percentage of adult health plan members who reported how often they were able to find out from their health plan how much they would have to pay for a healthcare service or specific prescription medicines.

Health plan members' experiences: percentage of adult health plan members who reported how often they were satisfied with their health plan's customer service.

Health plan members' experiences: percentage of adult health plan members who reported whether a doctor or other health provider included them in shared decision making.

Health plan members' satisfaction with care: adult health plan members' ratings of all health care received from their health plan in the last 12 months.

Health plan members' satisfaction with care: adult health plan members' ratings of the specialist they saw most often.

Health plan members' satisfaction with care: adult health plan members' ratings of their health plan.

Health plan members' satisfaction with care: adult health plan members' ratings of their personal doctor.

July 23, 2007

Physician Consortium for Performance Improvement®

Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older who had a spirometry evaluation results documented at least annually.

Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older with a diagnosis of COPD and an oxygen saturation less than or equal to 88% or a PaO₂ less than or equal to 55 mm Hg who prescribed long term oxygen therapy.

Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older with a diagnosis of COPD and dyspnea for whom exercise training was recommended.

Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older with a diagnosis of COPD and FEV₁ less than 40% of predicted value who have oxygen saturation assessed at least annually.

Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older with a diagnosis of COPD and who have an FEV₁/FVC less than 70% and have symptoms who were prescribed an inhaled bronchodilator.

Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older with a diagnosis of COPD identified as smokers who received a smoking cessation intervention at least annually.

Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older with a diagnosis of COPD who received a pneumococcus immunization.

Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older with a diagnosis of COPD who received influenza immunization during current flu season.

Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older with a diagnosis of COPD who were assessed for COPD symptoms at least annually.

Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older with a diagnosis of COPD who were assessed for pneumococcus immunization status.

Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older with a diagnosis of COPD who were queried about smoking at least annually.

Chronic obstructive pulmonary disease (COPD): percentage of patients aged 18 years and older with a diagnosis of COPD who were recommended to receive an influenza immunization annually.

July 16, 2007

Agency for Healthcare Research and Quality

Adult asthma: hospital admission rate. This updates a previously published measure summary.

Bacterial pneumonia: hospital admission rate. This updates a previously published measure summary.

Chronic obstructive pulmonary disease: hospital admission rate. This updates a previously published measure summary.

Congestive heart failure: hospital admission rate. This updates a previously published measure summary.

Coronary artery disease: angina without procedure hospital admission rate. This updates a previously published measure summary.

Dehydration: hospital admission rate. This updates a previously published measure summary.

Diabetes mellitus: hospital admission rate for long-term complications. This updates a previously published measure summary.

Diabetes mellitus: hospital admission rate for short-term complications. This updates a previously published measure summary.

Diabetes mellitus: hospital admission rate for uncontrolled diabetes. This updates a previously published measure summary.

Diabetes mellitus: lower-extremity amputation rate. This updates a previously published measure summary.

Health plan members' experiences: percentage of parents or guardians who reported how often it was easy for them to get needed care for their enrolled child.

Health plan members' experiences: percentage of parents or guardians who reported how often their enrolled child got care quickly.

Health plan members' experiences: percentage of parents or guardians who reported how often their enrolled child's personal doctor communicated well.

Health plan members' experiences: percentage of parents or guardians who reported how often they were satisfied with their enrolled child's health plan information and customer service.

Health plan members' satisfaction with care: parents' or guardians' overall ratings of their children's health care.

Health plan members' satisfaction with care: parents' or guardians' overall ratings of their children's health plan.

Health plan members' satisfaction with care: parents' or guardians' overall ratings of their children's personal doctor.

Health plan members' satisfaction with care: parents' or guardians' overall ratings of their children's specialist.

Hypertension: hospital admission rate. This updates a previously published measure summary.

Low birth weight: rate of infants with low birth weight. This updates a previously published measure summary.

Perforated appendix: hospital admission rate. This updates a previously published measure summary.

Urinary tract infection: hospital admission rate. This updates a previously published measure summary.

July 9, 2007

Agency for Healthcare Research and Quality

Health plan members' experiences: percentage of adult health plan members who reported how often it was easy for them to get needed care.

Health plan members' experiences: percentage of adult health plan members who reported how often their personal doctor communicated well.

Health plan members' experiences: percentage of adult health plan members who reported how often they get care quickly.

Health plan members' experiences: percentage of adult health plan members who reported how often they were satisfied with their health plan information and customer service.

Health plan members' satisfaction with care: adult health plan members' overall ratings of their health care.

Health plan members' satisfaction with care: adult health plan members' overall ratings of their health plan.

Health plan members' satisfaction with care: adult health plan members' overall ratings of their personal doctor.

Health plan members' satisfaction with care: adult health plan members' overall ratings of their specialist.

Institute for Clinical Systems Improvement

Stable coronary artery disease (CAD): percentage of patients with stable CAD who have aspirin use documented in the medical record. This updates a previously published measure summary.

Stable coronary artery disease (CAD): percentage of patients with stable CAD who have had a lipid profile determination at target (less than 100) and measured within the last year. This updates a previously published measure summary.

July 2, 2007

Centers for Medicare & Medicaid Services

Pneumonia: percent of immunocompetent patients with community-acquired pneumonia who receive an initial antibiotic regimen during the first 24 hours that is consistent with current guidelines. This updates a previously published measure summary.

Centers for Medicare & Medicaid Services/The Joint Commission

Pneumonia: percent of patients age 50 years and older, hospitalized during October, November, December, January, or February who were screened for influenza vaccine status and were vaccinated prior to discharge, if indicated. This updates a previously published measure summary.

Pneumonia: percent of patients aged 65 and older who were screened for pneumococcal vaccine status and were administered the vaccine prior to discharge, if indicated. This updates a previously published measure summary.

Pneumonia: percent of patients who had an assessment of arterial oxygenation by arterial blood gas measurement or pulse oximetry within 24 hours prior to or after arrival at the hospital. This updates a previously published measure summary.

Pneumonia: percent of patients who had blood cultures performed within 24 hours prior to or 24 hours after hospital arrival for patients who were transferred or admitted to the intensive care unit (ICU) within 24 hours of hospital arrival. This updates a previously published measure summary.

Pneumonia: percent of patients who receive their first dose of antibiotics within 4 hours after arrival at the hospital. This updates a previously published measure summary.

Pneumonia: percent of patients whose initial emergency department blood culture was performed prior to the administration of the first hospital dose of antibiotics. This updates a previously published measure summary.

Pneumonia: percent of patients with a history of smoking cigarettes who are given smoking cessation advice or counseling during hospital stay. This updates a previously published measure summary.

Joint Commission, The

Pneumonia: median time from arrival at the hospital to the administration of the first dose of antibiotic at the hospital. This updates a previously published measure summary.

Pneumonia: percent of immunocompetent intensive care unit (ICU) patients with community-acquired pneumonia who receive an initial antibiotic regimen during the first 24 hours that is consistent with current guidelines. This updates a previously published measure summary.

Pneumonia: percent of immunocompetent non-intensive care unit (ICU) patients with community-acquired pneumonia who receive an initial antibiotic regimen during the first 24 hours that is consistent with current guidelines. This updates a previously published measure summary.

Pneumonia: percent of patients who receive their first dose of antibiotics within 8 hours after arrival at the hospital. This updates a previously published measure summary.

June 25, 2007

Centers for Medicare & Medicaid Services/The Joint Commission

Heart failure: percent of patients discharged home with written instructions or educational material given to patient or caregiver at discharge or during the hospital stay addressing all of the following: activity level, diet, discharge medications, follow-up appointment, weight monitoring, and what to do if symptoms worsen. This updates a previously published measure summary.

Heart failure: percent of patients with a history of smoking cigarettes, who are given smoking cessation advice or counseling during hospital stay. This updates a previously published measure summary.

Heart failure: percent of patients with documentation in the hospital record that LVS function was evaluated before arrival, during hospitalization, or is planned for after discharge. This updates a previously published measure summary.

Heart failure: percent of patients with LVSD and without both ACEI and ARB contraindications who are prescribed an ACEI or ARB at hospital discharge. This updates a previously published measure summary.

Joint Commission, The

Pregnancy and related conditions: percent of live-born neonates who expire before the neonate becomes age 28 days. This updates a previously published measure summary.

Pregnancy and related conditions: percent of patients who have vaginal deliveries with third or fourth degree perineal laceration. This updates a previously published measure summary.

Pregnancy and related conditions: percent of patients with vaginal birth after cesarean section (VBAC). This updates a previously published measure summary.

June 18, 2007

Institute for Clinical Systems Improvement

Assessment and management of chronic pain: percentage of patients diagnosed with chronic pain who are prescribed an opioid who have documentation of an opioid agreement form in the medical record.

Atrial fibrillation: percentage of patients (without contraindications to anticoagulation) with paroxysmal, persistent, or permanent atrial fibrillation/atrial flutter (A Fib/Flutter) with risk factors for thromboembolism who are on warfarin. This updates a previously published measure summary.

Management of labor: percentage of births with amnioinfusion when either of the following is present: thick meconium or repetitive severe variable decelerations or oligohydramnios. This updates a previously published measure summary.

Management of labor: percentage of women in the guideline population who have spontaneous rupture of membranes (SROM) or early amniotomy. This updates a previously published measure summary.

Management of labor: percentage of women in the guideline population with failure to progress diagnosis who have oxytocin. This updates a previously published measure summary.

Management of labor: percentage of women who are assessed for risk status on entry to labor and delivery. This updates a previously published measure summary.

June 11, 2007

State of Wisconsin, Department of Health and Family Services

Inpatient care: all inpatient medical stays excluding maternity and mental health/substance abuse (MEDDIC-MS SSI).

Inpatient care: all inpatient psychiatric stays (MEDDIC-MS SSI).

Inpatient care: all inpatient stays for hospice, rehabilitation, and respite care (MEDDIC-MS SSI).

Inpatient care: all inpatient substance abuse stays (MEDDIC-MS SSI).

Inpatient care: all surgical stays (MEDDIC-MS SSI).

Mental health and/or substance abuse: percent of enrollees receiving at least one outpatient mental health or substance abuse evaluation (MEDDIC-MS SSI).

Mental health: percent of enrollees diagnosed with non-organic, non-substance abuse mental health disorder receiving day/outpatient mental health treatment (MEDDIC-MS SSI). This updates a previously published measure summary.

Substance abuse: percent of enrollees with substance abuse diagnosis receiving day/outpatient substance abuse treatment (MEDDIC-MS SSI). This updates a previously published measure summary.

June 4, 2007

State of Wisconsin, Department of Health and Family Services

Cervical cancer detection: percent of enrollees who had at least one Pap test in the measure look-back period (MEDDIC-MS SSI). This updates a previously published measure summary.

Cervical cancer detection: percent of women diagnosed with cervical/uterine malignancy among those screened (MEDDIC-MS SSI).

Cervical cancer detection: percent of women diagnosed with human papillomavirus (HPV) detected among those screened (MEDDIC-MS SSI).

General and specialty care: percent of enrollees receiving care in an emergency department (ED) of an acute care provider facility without subsequent admission to an inpatient care facility as a direct result of the ED visit (MEDDIC-MS SSI).

General and specialty care: percent of enrollees with one or more audiology encounters (MEDDIC-MS SSI).

General and specialty care: percent of enrollees with one or more dental encounters (MEDDIC-MS SSI).

General and specialty care: percent of enrollees with one or more primary care encounters and total number of all primary care encounters (MEDDIC-MS SSI).

General and specialty care: percent of enrollees with one or more vision care encounters (MEDDIC-MS SSI).

May 28, 2007

British Medical Association

Diabetes mellitus: the percentage of patients with diabetes in whom the last blood pressure is 145/85 or less.

Diabetes mellitus: the percentage of patients with diabetes who have a record of estimated glomerular filtration rate (eGFR) or serum creatinine testing in the previous 15 months.

Diabetes mellitus: the percentage of patients with diabetes who have a record of micro-albuminuria testing in the previous 15 months (exception reporting for patients with proteinuria).

Diabetes mellitus: the percentage of patients with diabetes who have a record of the blood pressure in the previous 15 months.

Diabetes mellitus: the percentage of patients with diabetes who have a record of total cholesterol in the previous 15 months.

Diabetes mellitus: the percentage of patients with diabetes who have had influenza immunisation in the preceding 1 September to 31 March.

Diabetes mellitus: the percentage of patients with diabetes whose last measured total cholesterol within the previous 15 months is 5 mmol/l or less.

Diabetes mellitus: the percentage of patients with diabetes with a diagnosis of proteinuria or micro-albuminuria who are treated with angiotensin-converting enzyme (ACE) inhibitors (or angiotensin II [A2] antagonists).

May 21, 2007

British Medical Association

Diabetes mellitus: the percentage of patients with diabetes in whom the last HbA1c is 10 or less (or equivalent test/reference range depending on local laboratory) in the previous 15 months.

Diabetes mellitus: the percentage of patients with diabetes in whom the last HbA1c is 7.5 or less (or equivalent test/reference range depending on local laboratory) in the previous 15 months.

Diabetes mellitus: the percentage of patients with diabetes who have a record of HbA1c or equivalent in the previous 15 months.

Diabetes mellitus: the percentage of patients with diabetes who have a record of retinal screening in the previous 15 months.

Diabetes mellitus: the percentage of patients with diabetes whose notes record body mass index (BMI) in the previous 15 months.

Diabetes mellitus: the percentage of patients with diabetes with a record of neuropathy testing in the previous 15 months.

Diabetes mellitus: the percentage of patients with diabetes with a record of the presence or absence of peripheral pulses in the previous 15 months.

Diabetes mellitus: the practice can produce a register of all patients aged 17 years and over with diabetes mellitus, which specifies whether the patient has Type 1 or Type 2 diabetes.

May 14, 2007

British Medical Association

Stroke and transient ischaemic attack (TIA): the percentage of new patients with a stroke who have been referred for further investigation.

Stroke and transient ischaemic attack (TIA): the percentage of patients with a history of TIA or stroke in whom the last blood pressure reading (measured in previous 15 months) is 150/90 or less.

Stroke and transient ischaemic attack (TIA): the percentage of patients with a stroke shown to be non-haemorrhagic, or a history of TIA, who have a record that an anti-platelet agent (aspirin, clopidogrel, dipyridamole or a combination), or anti-coagulant is being taken (unless a contraindication or side-effects are recorded).

Stroke and transient ischaemic attack (TIA): the percentage of patients with TIA or stroke who have a record of blood pressure in the notes in the preceding 15 months.

Stroke and transient ischaemic attack (TIA): the percentage of patients with TIA or stroke who have a record of total cholesterol in the last 15 months.

Stroke and transient ischaemic attack (TIA): the percentage of patients with TIA or stroke who have had influenza immunisation in the preceding 1 September to 31 March.

Stroke and transient ischaemic attack (TIA): the percentage of patients with TIA or stroke whose last measured total cholesterol (measured in previous 15 months) is 5 mmol/l or less.

Stroke and transient ischaemic attack (TIA): the practice can produce a register of patients with stroke or TIA.

May 7, 2007

State of Wisconsin, Department of Health and Family Services

Ambulatory care management of diabetes: percent of patients with at least one hemoglobin A1c (HbA1c) test conducted in the measure look-back period (MEDDIC-MS SSI). This updates a previously published measure summary.

Ambulatory care management of diabetes: percent of patients with at least one lipid profile test in the look-back period (MEDDIC-MS SSI). This updates a previously published measure summary.

Post-hospitalization care for mental illness/substance abuse: percentage of discharges that were followed by an ambulatory mental health or substance abuse encounter or day/night treatment with a primary care provider within 7 and 30 days of hospital discharge (MEDDIC-MS SSI). This updates a previously published measure summary.

Post-hospitalization care for mental illness/substance abuse: percentage of discharges that were followed by an ambulatory mental health or substance abuse encounter or day/night treatment with a specialist mental health/substance abuse provider within 7 and 30 days of hospital discharge (MEDDIC-MS SSI). This updates a previously published measure summary.

Post-hospitalization care for mental illness/substance abuse: percentage of discharges that were followed by an ambulatory mental health or substance abuse encounter or day/night treatment with other or unspecified provider within 7 and 30 days of hospital discharge (MEDDIC-MS SSI). This updates a previously published measure summary.

Post-hospitalization care for substance abuse: percentage of discharges that were followed by an ambulatory substance abuse encounter with a primary care provider within 7 and 30 days of hospital discharge (MEDDIC-MS SSI). This updates a previously published measure summary.

Post-hospitalization care for substance abuse: percentage of discharges that were followed by an ambulatory substance abuse encounter with a specialist mental health or substance abuse provider within 7 and 30 days of hospital discharge (MEDDIC-MS SSI). This updates a previously published measure summary.

Post-hospitalization care for substance abuse: percentage of discharges that were followed by an ambulatory substance abuse encounter with an other or unspecified provider within 7 and 30 days of hospital discharge (MEDDIC-MS SSI). This updates a previously published measure summary.

Preventive dental care: percent of enrollees age 18+ years who had at least one preventive dental service during the look-back period (MEDDIC-MS SSI). This updates a previously published measure summary.

April 30, 2007

Centers for Medicare & Medicaid Services

End stage renal disease (ESRD): percentage of adult hemodialysis (HD) or peritoneal dialysis (PD) patients receiving Epoetin therapy with documented mean hemoglobin (Hgb) of 11-12 g/dL (110-120 g/L) during the study period. This updates a previously published measure summary.

End stage renal disease (ESRD): percentage of adult hemodialysis (HD) patients with anemia or if prescribed Epoetin with at least one documented transferrin saturation and serum ferritin concentration result every three months. This updates a previously published measure summary.

End stage renal disease (ESRD): percentage of adult hemodialysis (HD) patients with anemia or if prescribed Epoetin with at least one documented transferrin saturation greater than or equal to 20 percent and at least one documented serum ferritin concentration greater than or equal to 100 ng/mL during a three-month period. This updates a previously published measure summary.

End stage renal disease (ESRD): percentage of adult hemodialysis (HD) patients with anemia or prescribed Epoetin with at least one transferrin saturation less than 20 percent or at least one serum ferritin concentration less than 100 ng/mL who were prescribed intravenous iron in at least one of the study months. This updates a previously published measure summary.

End stage renal disease (ESRD): percentage of adult patients who were dialyzed with a chronic catheter continuously for 90 days or longer prior to the last hemodialysis (HD) session during the study period. This updates a previously published measure summary.

End stage renal disease (ESRD): percentage of adult patients whose arterial venous (AV) graft was routinely surveyed (screened) for the presence of stenosis during the study period. This updates a previously published measure summary.

End stage renal disease (ESRD): percentage of adult peritoneal dialysis (PD) patients with anemia or if prescribed Epoetin with at least one documented transferrin saturation greater than or equal to 20 percent and at least one documented serum ferritin concentration greater than or equal to 100 ng/mL during the six-month study period. This updates a previously published measure summary.

End stage renal disease (ESRD): percentage of adult peritoneal dialysis (PD) patients with anemia or if prescribed Epoetin with at least two documented transferrin saturation and serum ferritin concentration results over the six-month study period. This updates a previously published measure summary.

End stage renal disease (ESRD): percentage of adult peritoneal dialysis (PD) patients with anemia or prescribed Epoetin with at least one transferrin saturation less than 20 percent or at least one serum ferritin concentration less than 100 ng/mL who were prescribed intravenous iron in at least one of the two-month periods during the six-month study period. This updates a previously published measure summary.

April 23, 2007

Centers for Medicare & Medicaid Services

End stage renal disease (ESRD): percentage of adult continuous ambulatory peritoneal dialysis (CAPD) patients for whom the delivered PD dose was a weekly Kt/V_urea of at least 2.0 and a weekly creatinine clearance (CrCl) of at least 60 L/week/1.73 m² or evidence that the prescription was changed according to National Kidney Foundation/Kidney Disease Outcomes Quality Initiative (NKF-K/DOQI) recommendations, during the study period. This updates a previously published measure summary.

End stage renal disease (ESRD): percentage of adult continuous cycling peritoneal dialysis (CCPD) patients for whom the delivered PD dose was a weekly Kt/V_urea of at least 2.1 and a weekly creatinine clearance (CrCl) of at least 63 L/week/1.73 m² or evidence that the prescription was changed according to National Kidney Foundation/Kidney Disease Outcomes Quality Initiative (NKF-K/DOQI) recommendations, during the study period. This updates a previously published measure summary.

End stage renal disease (ESRD): percentage of adult hemodialysis (HD) patients for whom delivered HD dose was calculated using formal urea kinetic modeling or Daugirdas II during the study period. This updates a previously published measure summary.

End stage renal disease (ESRD): percentage of adult hemodialysis (HD) patients whose average delivered dose of HD was a single-pool Kt/V (spKt/V) greater than or equal to 1.2 during the study period. This updates a previously published measure summary.

End stage renal disease (ESRD): percentage of adult hemodialysis (HD) patients with documented monthly adequacy measurements (urea reduction ratio [URR] or single-pool Kt/V [spKt/V]) during the study period. This updates a previously published measure summary.

End stage renal disease (ESRD): percentage of adult nightly intermittent peritoneal dialysis (NIPD) patients for whom the delivered PD dose was a weekly Kt/V_urea of at least 2.2 and a weekly creatinine clearance (CrCl) of at least 66 L/week/1.73 m² or evidence that the prescription was changed according to National Kidney Foundation/Kidney Disease Outcomes Quality Initiative (NKF-K/DOQI) recommendations, during the study period. This updates a previously published measure summary.

End stage renal disease (ESRD): percentage of adult peritoneal dialysis (PD) patients with total solute clearance for urea and creatinine measured at least once in a 6 month time period. This updates a previously published measure summary.

End stage renal disease (ESRD): percentage of adult peritoneal dialysis (PD) patients with weekly Kt/V_urea and creatinine clearance (CrCl) calculated in a standard way. This updates a previously published measure summary.

End stage renal disease (ESRD): percentage of incident adult hemodialysis (HD) patients who were dialyzed using an arterial venous fistula (AVF) during their last HD treatment during the study period. This updates a previously published measure summary.

End stage renal disease (ESRD): percentage of prevalent adult hemodialysis (HD) patients who were dialyzed using an arterial venous fistula (AVF) during their last HD treatment during the study period. This updates a previously published measure summary.

Institute for Clinical Systems Improvement

Diagnosis and treatment of respiratory illness in children and adults: percentage of encounters for cold symptoms (phone care and/or office visits) for which there is documentation of home treatment education. This updates a previously published measure summary.

Diagnosis and treatment of respiratory illness in children and adults: percentage of patients with a diagnosis of pharyngitis that had strep screen testing.

Diagnosis and treatment of respiratory illness in children and adults: percentage of patients with an office visit for cold symptoms who have had symptoms for less than 7 days and who receive an antibiotic. This updates a previously published measure summary.

April 16, 2007

Arthritis Foundation

Rheumatoid arthritis: percentage of female patients of childbearing age who are newly started on any of the following disease-modifying antirheumatic drugs (DMARDs): methotrexate, cyclophosphamide, azathioprine, sulfasalazine, chlorambucil, D-penicillamine, hydroxychloroquine, gold, etanercept, infliximab, leflunomide for whom a discussion with the patient about the teratogenic risks of these drugs and about contraception is documented.

Rheumatoid arthritis: percentage of patients in the third trimester of pregnancy for whom non-steroidal anti-inflammatory drugs (NSAIDs) (selective and non-selective) and aspirin are not used.

Rheumatoid arthritis: percentage of patients newly prescribed acetaminophen for whom the risk versus benefits of this drug are discussed.

Rheumatoid arthritis: percentage of patients newly prescribed any of the following drugs: non-steroidal anti-inflammatory drugs (NSAIDs) (selective or non-selective), disease-modifying antirheumatic drugs (DMARDs), glucocorticoids, or narcotics for whom a discussion with the patient about the risks versus benefits of the chosen therapy is documented.

Rheumatoid arthritis: percentage of patients on immunosuppressive therapy for whom there is evidence that the following vaccines have been given: influenza (annually), pneumococcal, meningococcal, haemophilus B, hepatitis B, and tetanus.

Rheumatoid arthritis: percentage of patients receiving immunosuppressants and/or steroid therapy (greater than 10 mg per day prednisone equivalent for greater than two weeks) for whom live/oral polio, live typhoid, yellow fever, measles, mumps, rubella (MMR), bacille Calmette-Guerin (BCG) vaccine are not used.

Rheumatoid arthritis: percentage of pregnant patients for whom methotrexate and leflunomide are not used.

Institute for Clinical Systems Improvement

Chronic obstructive pulmonary disease (COPD): percentage of patients with COPD whose physician inquired about smoking cessation (if patient a smoker) at every visit. This updates a previously published measure summary.

State of Wisconsin, Department of Health and Family Services

Asthma care: percent of enrollees with a diagnosis of asthma (MEDDIC-MS SSI).

Asthma care: percent of enrollees with a diagnosis of asthma with at least one emergency department encounter with a principal diagnosis of asthma (MEDDIC-MS SSI). This updates a previously published measure summary.

Asthma care: percent of enrollees with a diagnosis of asthma with at least one inpatient discharge with a principal diagnosis of asthma (MEDDIC-MS SSI). This updates a previously published measure summary.

Breast cancer detection: percent of enrollees who had at least one mammogram in the measure look-back period (MEDDIC-MS SSI). This updates a previously published measure summary.

Breast cancer detection: percent of women diagnosed with breast malignancy among those screened (MEDDIC-MS SSI).

April 9, 2007

Arthritis Foundation

Rheumatoid arthritis: percentage of patients being treated with methotrexate (MTX) who have elevations in serum transaminase levels above two times the upper range of normal for the laboratory two or more times over a three month period for whom non-steroidal anti-inflammatory drug (NSAID) or MTX dose reduction or discontinuation is documented within one month of the second abnormal laboratory result.

Rheumatoid arthritis: percentage of patients receiving greater than or equal to 10 mg per day of prednisone (or equivalent) for greater than six months with no documentation of worsening disease for whom there is documentation at some point during the treatment course that a steroid taper was attempted or a disease-modifying antirheumatic drug (DMARD) dose was increased.

Rheumatoid arthritis: percentage of patients with a diagnosis of rheumatoid arthritis reporting having difficulties performing tasks involving use of their hands and wrists either because of stiffness or pain for whom functional ability with their hands and wrists is assessed for need of hand or wrist splints (orthoses).

Rheumatoid arthritis: percentage of patients with a diagnosis of rheumatoid arthritis reporting having difficulties with activities of daily living either because of stiffness or pain for whom functional ability with the compliant tasks is assessed for need of assistive devices to aid with compliant tasks.

Rheumatoid arthritis: percentage of patients with a diagnosis of rheumatoid arthritis reporting having difficulty with walking either because of stiffness, pain or instability for whom walking ability is assessed for need for ambulatory assistive devices including a cane, insoles, and orthotics.

Rheumatoid arthritis: percentage of patients with a diagnosis of rheumatoid arthritis, no contraindications to exercise and who are physically and mentally able to exercise for whom a directed or supervised muscle strengthening or aerobic exercise program has been prescribed at least once and reviewed at least once per year.

Rheumatoid arthritis: percentage of patients with established treatment with a disease-modifying antirheumatic drug (DMARD) or glucocorticoids for whom monitoring for drug toxicity is performed.

Rheumatoid arthritis: percentage of patients with rheumatoid arthritis who are newly prescribed a disease-modifying antirheumatic drug (DMARD) for whom appropriate baseline studies are documented within an appropriate period of time from the original prescription.

Rheumatoid arthritis: percentage of patients with rheumatoid arthritis who have joint pain, joint instability, or tendon rupture affecting the upper extremity or the foot or ankle, which significantly limits activities despite non-pharmacologic and pharmacologic interventions for whom referral to a surgeon is offered unless contraindication to surgery is documented.

Rheumatoid arthritis: percentage of patients with rheumatoid arthritis who have severe pain of the hips or knees, which significantly limits activities despite non-pharmacologic and pharmacologic interventions for whom referral to an orthopedic surgeon is offered unless contraindication to surgery is documented.

April 2, 2007

Arthritis Foundation

Rheumatoid arthritis: percentage of patients being treated with methotrexate for whom folate supplementation is given.

Rheumatoid arthritis: percentage of patients referred to a physician for a new diagnosis of rheumatoid arthritis who are seen by the physician within 3 months.

Rheumatoid arthritis: percentage of patients with a diagnosis of rheumatoid arthritis (RA) for whom baseline x-rays of the hands or feet are performed within 3 months of the initial diagnosis and every 3 years.

Rheumatoid arthritis: percentage of patients with a diagnosis of rheumatoid arthritis for whom each of the following are documented within 3 months of diagnosis and at appropriate time intervals thereafter: a joint examination of three or more joint areas, functional status, disease activity (presence/absence of synovitis), acute phase reactant (defined by erythrocyte sedimentation rate [ESR] or C-reactive protein [CRP]) and pain (by visual analog scale [VAS] or other mechanism).

Rheumatoid arthritis: percentage of patients with an established diagnosis of rheumatoid arthritis (RA) whose RA is evaluated by a physician at least annually.

Rheumatoid arthritis: percentage of patients with an established diagnosis of sero-positive rheumatoid arthritis (RA), or RA and synovitis or RA and radiographic erosions who are treated with a disease-modifying antirheumatic drug (DMARD) unless contraindication to DMARD is documented.

Rheumatoid arthritis: percentage of patients with rheumatoid arthritis and osteoporosis treated with oral or parenteral steroids for whom antiresorptive therapy is prescribed.

Rheumatoid arthritis: percentage of patients with rheumatoid arthritis started on prednisone greater than or equal to 10 mgs daily, (or other steroid equivalent) and who continue on prednisone for more than three months for whom 1,500 mg calcium and 400 international units (IUs) per day of Vitamin D are prescribed and antiresorptive therapy is discussed with the patient.

Rheumatoid arthritis: percentage of patients with rheumatoid arthritis who are being treated with a disease-modifying antirheumatic drug (DMARD) and report worsening of symptoms over a six-month period of time and have evidence of active disease (synovitis) for whom one of the following are done: dose or route of DMARD administration is changed, DMARD is changed, an additional DMARD is added, or dose of glucocorticoids is started or increased.

Rheumatoid arthritis: percentage of patients with rheumatoid arthritis who have surgery requiring general anesthesia for whom there is management or documentation of the risk of atlanto-axial instability.

March 26, 2007

HRSA Health Disparities Collaboratives: Diabetes Collaborative

Diabetes mellitus: percent of patients 12 to 70 years of age who are not already on angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) and have had a microalbuminuria screening test in the last 12 months.

Diabetes mellitus: percent of patients who are current smokers (documented in the last 12 months).

Diabetes mellitus: percent of patients who have had a comprehensive foot exam in the past 12 months.

Diabetes mellitus: percent of patients who have had a dilated eye exam in last 12 months.

Diabetes mellitus: percent of patients who have had one pneumococcal vaccination at any time.

Diabetes mellitus: percent of patients who obtained an influenza vaccination in the last 12 months.

Diabetes mellitus: percent of patients whose last documented exercise rate (within the last 12 months) was three times per week for at least 20 minutes.

Diabetes mellitus: percent of patients with a body mass index (BMI) greater than 25 who have lost 10 pounds at any time in the last 12 months.

Diabetes mellitus: percent of patients with a documented screening for depression in the past 12 months.

March 19, 2007

HRSA Health Disparities Collaboratives: Diabetes Collaborative

Diabetes mellitus: average HbA1c value for diabetic patients in the clinical information system.

Diabetes mellitus: percent of patients 40 years and older who have a current prescription for aspirin or other antithrombotic agent.

Diabetes mellitus: percent of patients 40 years and older who have a current prescription for statins.

Diabetes mellitus: percent of patients 55 years and older who have a current prescription for angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blocker (ARB) medication.

Diabetes mellitus: percent of patients who obtained a dental exam in the last 12 months.

Diabetes mellitus: percent of patients whose most recent fasting low-density lipoprotein (LDL) was less than 100 (in the last 12 months).

Diabetes mellitus: percent of patients with 2 HbA1c's in the last year (at least 3 months apart).

Diabetes mellitus: percent of patients with blood pressure reading less than 130/80 in the last 12 months.

Diabetes mellitus: percent of patients with documented self-management goals in the last 12 months.

March 12, 2007

British Medical Association

Atrial fibrillation: the percentage of patients with atrial fibrillation diagnosed after 1 April 2006 with electrocardiogram (ECG) or specialist confirmed diagnosis.

Atrial fibrillation: the percentage of patients with atrial fibrillation who are currently treated with anti-coagulation drug therapy or an anti-platelet therapy.

Atrial fibrillation: the practice can produce a register of patients with atrial fibrillation.

Smoking: the percentage of patients with any or any combination of the following conditions: coronary heart disease (CHD), stroke or transient ischaemic attack (TIA), hypertension, diabetes, chronic obstructive pulmonary disease (COPD), or asthma who smoke whose notes contain a record that smoking cessation advice or referral to a specialist service, where available, has been offered within the previous 15 months.

Smoking: the percentage of patients with any or any combination of the following conditions: coronary heart disease (CHD), stroke or transient ischaemic attack (TIA), hypertension, diabetes, chronic obstructive pulmonary disease (COPD), or asthma whose notes record smoking status in the previous 15 months.

Institute for Clinical Systems Improvement

Management of type 2 diabetes mellitus: frequency of low-density lipoprotein (LDL) cholesterol values in adult patients with diabetes by category: less than 100 mg/dL, 100-130 mg/dL, greater than 130 mg/dL, incalculable, untested. This updates a previously published measure summary.

Management of type 2 diabetes mellitus: percentage of adult patients with diabetes with A1C less than 7%. This updates a previously published measure summary.

Management of type 2 diabetes mellitus: percentage of patients who have had a screen for A1C in the past six months, an annual low-density lipoprotein (LDL) test, A1C value less than 7%, LDL less than 100 mg/dL, blood pressure less than 130/80 mmHg, who don't use tobacco and are regularly using aspirin. This updates a previously published measure summary.

Management of type 2 diabetes mellitus: percentage of patients with diabetes mellitus with A1C measured in the last six months. This updates a previously published measure summary.

Management of type 2 diabetes mellitus: percentage of patients with diabetes with eye exam documented within last 12 months. This updates a previously published measure summary.

Management of type 2 diabetes mellitus: percentage of patients with diabetes with microalbumin tested within the last 12 months. This updates a previously published measure summary.

March 5, 2007

State of Wisconsin, Department of Health and Family Services

Breast cancer detection: percent of enrollees who had at least one mammogram in the measure look-back period (MEDDIC-MS). This updates a previously published measure summary.

Breast cancer detection: percent of women diagnosed with breast malignancy among those screened (MEDDIC MS).

Cervical cancer detection: percent of enrollees who had at least one Pap test in the measure look-back period (MEDDIC-MS). This updates a previously published measure summary.

Cervical cancer detection: percent of women diagnosed with cervical/uterine pre-malignant or malignant lesions among those screened (MEDDIC-MS).

Cervical cancer detection: percent of women with human papillomavirus (HPV) detected among those screened (MEDDIC-MS).

Child health: percent of children who received at least one non-EPSDT (non-HealthCheck), well-child examination or at least one non-EPSDT (non-HealthCheck), non-well-child encounter in the look-back period (MEDDIC-MS). This updates a previously published measure summary.

EPSDT -- early and periodic screening, diagnostic and treatment (HealthCheck) services: percent of children who received at least one EPSDT (HealthCheck) examination in the look-back period (MEDDIC-MS). This updates a previously published measure summary.

EPSDT -- early and periodic screening, diagnostic and treatment (HealthCheck) services: percent of children who received seven or more, six, or five comprehensive HealthCheck examinations by the age of two years (MEDDIC-MS). This updates a previously published measure summary.

General and specialty care: percent of enrollees receiving at least one encounter of care in an emergency department (ED) of an acute care provider facility without subsequent admission to an inpatient care facility as a direct result of the ED visit (MEDDIC-MS).

General and specialty care: percent of enrollees with one or more audiology encounters (MEDDIC-MS).

General and specialty care: percent of enrollees with one or more dental encounters (MEDDIC-MS).

General and specialty care: percent of enrollees with one or more primary care encounters and total number of all primary care encounters (MEDDIC-MS).

General and specialty care: percent of enrollees with one or more vision care encounters (MEDDIC-MS).

Mental health and/or substance abuse: percent of enrollees receiving at least one outpatient mental health or substance abuse evaluation (MEDDIC-MS).

Mental health: percentage of enrollees diagnosed with a non-organic, non-substance abuse mental health disorder receiving day/outpatient mental health treatment provided by mental health specialists (MEDDIC-MS). This updates a previously published measure summary.

Mental health: percentage of enrollees diagnosed with a non-organic, non-substance abuse mental health disorder receiving day/outpatient mental health treatment provided by primary care providers (PCPs)/unspecified providers (MEDDIC-MS). This updates a previously published measure summary.

Preventive dental care: percent of patients age 21 years and older who have had at least one preventive dental service in the look-back period (MEDDIC-MS). This updates a previously published measure summary.

Preventive dental care: percent of patients age 3 to 20 years who have had at least one preventive dental service in the look-back period (MEDDIC-MS). This updates a previously published measure summary.

Substance abuse: percentage of enrollees with a substance abuse diagnosis receiving day/outpatient substance abuse treatment provided by primary care providers (PCPs)/unspecified providers (MEDDIC-MS). This updates a previously published measure summary.

Substance abuse: percentage of enrollees with a substance abuse diagnosis receiving day/outpatient substance abuse treatment provided by substance abuse specialists (MEDDIC-MS). This updates a previously published measure summary.

February 26, 2007

Institute for Clinical Systems Improvement

Diagnosis and treatment of chest pain and acute coronary syndrome (ACS): percentage of patients with acute myocardial infarction (AMI) receiving beta-blockers within 24 hours of arrival and on discharge. This updates a previously published measure summary.

Diagnosis and treatment of chest pain and acute coronary syndrome (ACS): percentage of patients with acute myocardial infarction (AMI) receiving or scheduled for a risk stratifying procedure prior to discharge. This updates a previously published measure summary.

Diagnosis and treatment of chest pain and acute coronary syndrome (ACS): percentage of patients with acute myocardial infarction (AMI) receiving thrombolytics with a "door-to-drug time" (time from presentation to administration of drug) of less than 30 minutes. This updates a previously published measure summary.

Diagnosis and treatment of chest pain and acute coronary syndrome (ACS): percentage of patients with chest pain symptoms in emergency department (ED) receiving early therapy including intravenous (IV) access, oxygen, nitroglycerin, morphine and a chewable aspirin on arrival. This updates a previously published measure summary.

Diagnosis and treatment of chest pain and acute coronary syndrome (ACS): percentage of patients with chest pain symptoms who have had treadmill tests with the Duke score present and aren't high risk. This updates a previously published measure summary.

State of Wisconsin, Department of Health and Family Services

Inpatient care: all inpatient hospitalizations for maternity-related diagnoses (MEDDIC-MS).

Inpatient care: all inpatient medical stays excluding maternity and mental health/substance abuse (MEDDIC-MS).

Inpatient care: all inpatient psychiatric stays (MEDDIC-MS).

Inpatient care: all inpatient stays for hospice, rehabilitation and respite care (MEDDIC-MS).

Inpatient care: all inpatient substance abuse stays (MEDDIC-MS).

Inpatient care: all newborn care provided from birth to discharge home (MEDDIC-MS).

Inpatient care: all surgical stays (MEDDIC-MS).

February 19, 2007

Eisen, Susan V. PhD

Mental health/substance abuse: mean of patient's change scores on the "Interpersonal Relationships" subscale of the BASIS-24® survey.

Mental health/substance abuse: mean of patients' change scores on the "Depression/Functioning" subscale of the BASIS-24® survey.

Mental health/substance abuse: mean of patients' change scores on the "Emotional Lability" subscale of the BASIS-24® survey.

Mental health/substance abuse: mean of patients' change scores on the "Psychosis" subscale of the BASIS-24® survey.

Mental health/substance abuse: mean of patients' change scores on the "Self-harm" subscale of the BASIS-24® survey.

Mental health/substance abuse: mean of patients' change scores on the "Substance Abuse" subscale of the BASIS-24® survey.

Mental health/substance abuse: mean of patients' overall change scores on the BASIS-24® survey.

Institute for Clinical Systems Improvement

Hypertension diagnosis and treatment: percentage of patients who have blood pressure less than 140/90 mmHg at the clinic visit. This updates a previously published measure summary.

Hypertension diagnosis and treatment: percentage of patients with hypertension presenting in clinic within the last month for whom patient education about modifiable risk factors has been documented in the medical record. This updates a previously published measure summary.

Prevention and management of obesity (mature adolescents and adults): percentage of patients with a documented Body Mass Index (BMI) equal to or greater than 25 who were given education and counsel for weight loss strategies. This updates a previously published measure summary.

Preventive services for adults: percentage of patients with all Level I preventive services on time according to the guideline delivery schedule. This updates a previously published measure summary.

Preventive services for children and adolescents: the percentage of patients who are on time with recommended immunizations. This updates a previously published measure summary.

February 12, 2007

Institute for Clinical Systems Improvement

Initial management of abnormal cervical cytology (Pap smear) and human papillomavirus (HPV) testing: percentage of adult women diagnosed with initial abnormal cervical cytology of atypical squamous cells of undetermined significance (ASCUS) with high-risk HPV type who have follow-up colposcopy within six months of abnormality identified. This updates a previously published measure summary.

State of Wisconsin, Department of Health and Family Services

Asthma care: number of enrollees with a diagnosis of asthma (MEDDIC-MS).

Asthma care: percent of enrollees with a diagnosis of asthma with at least one emergency department encounter with a principal diagnosis of asthma (MEDDIC-MS). This updates a previously published measure summary.

Asthma care: percent of enrollees with a diagnosis of asthma with at least one inpatient discharge with a principal diagnosis of asthma (MEDDIC-MS). This updates a previously published measure summary.

Maternity care: percent of enrollees who received prenatal care coordination (MEDDIC-MS). This updates a previously published measure summary.

Maternity care: percent of enrollees who received substance abuse treatment services during the look-back period (MEDDIC-MS).

Maternity care: percent of enrollees who received testing for HIV during the look-back period (MEDDIC-MS). This updates a previously published measure summary.

Maternity care: percent of enrollees with delivery by Cesarean section (MEDDIC-MS).

Post-hospitalization care for mental illness/substance abuse: percentage of discharges that were followed by an ambulatory mental health or substance abuse encounter or day/night treatment with a primary care provider within 7 and 30 days of hospital discharge (MEDDIC-MS). This updates a previously published measure summary.

Post-hospitalization care for mental illness/substance abuse: percentage of discharges that were followed by an ambulatory mental health or substance abuse encounter or day/night treatment with a specialist mental health/substance abuse provider within 7 and 30 days of hospital discharge (MEDDIC-MS). This updates a previously published measure summary.

Post-hospitalization care for mental illness/substance abuse: percentage of discharges that were followed by an ambulatory mental health or substance abuse encounter or day/night treatment with an other or unspecified provider within 7 and 30 days of hospital discharge (MEDDIC-MS). This updates a previously published measure summary.

February 5, 2007

British Medical Association

Chronic kidney disease (CKD): the percentage of patients on the CKD register in whom the last blood pressure reading, measured in the previous 15 months, is 140/85 or less.

Chronic kidney disease (CKD): the percentage of patients on the CKD register whose notes have a record of blood pressure in the previous 15 months.

Chronic kidney disease (CKD): the percentage of patients on the CKD register with hypertension who are treated with an angiotensin-converting enzyme inhibitor (ACE-I) or angiotensin receptor blocker (ARB) (unless a contraindication or side effects are recorded).

Chronic kidney disease (CKD): the practice can produce a register of patients aged 18 years and over with CKD (US National Kidney Foundation: Stage 3 to 5 CKD).

State of Wisconsin, Department of Health and Family Services

Ambulatory diabetes care: percent of patients with at least one hemoglobin A1c (HbA1c) test conducted in the measure look-back period (MEDDIC-MS). This updates a previously published measure summary.

Ambulatory diabetes care: percent of patients with at least one lipid profile test in the look-back period (MEDDIC-MS). This updates a previously published measure summary.

Blood lead toxicity screening: percentage of enrolled children who had a blood lead screening performed with a date of service between ages 17 and 28 months (MEDDIC-MS). This updates a previously published measure summary.

Blood lead toxicity screening: percentage of enrolled children who had a blood lead screening performed with a date of service between ages 6 and 16 months (MEDDIC-MS). This updates a previously published measure summary.

Childhood immunizations (full coverage): percent of enrolled children who received all of the following by the measure end date: four DTaP, DT, or DTP with different dates of service, or some combination of DTaP, DTP or DTP/DT vaccines adding up to 4 doses, three polio (IPV/OPV) vaccinations with different dates of service, one measles vaccination, one mumps vaccination, one rubella vaccination or one MMR vaccination, one varicella (VZV) vaccination, three H influenza type B (Hib) vaccinations, three hepatitis B vaccinations (MEDDIC-MS). This updates a previously published measure summary.

Childhood immunizations (substantial coverage): percent of enrolled children who received all of the following by the measure end date: three DTaP, DT, or DTP with different dates of service, or some combination of DTaP, DTP or DTP/DT vaccines adding up to 3 doses, three polio (IPV/OPV) vaccinations with different dates of service, one measles vaccination, one mumps vaccination, one rubella vaccination or one MMR vaccination, two H influenza type B (Hib) vaccinations, two hepatitis B vaccinations (MEDDIC-MS). This updates a previously published measure summary.

January 29, 2007

Agency for Healthcare Research and Quality

Acute myocardial infarction (AMI): mortality rate, without transfer cases. This updates a previously published measure summary.

Acute myocardial infarction (AMI): mortality rate. This updates a previously published measure summary.

Acute stroke: mortality rate. This updates a previously published measure summary.

Cholecystitis/cholelithiasis: laparoscopic cholecystectomy rate. This updates a previously published measure summary.

Congestive heart failure (CHF): mortality rate. This updates a previously published measure summary.

Coronary artery disease: bilateral cardiac catheterization rate. This updates a previously published measure summary.

Craniotomy: mortality rate. This updates a previously published measure summary.

Gastrointestinal (GI) hemorrhage: mortality rate. This updates a previously published measure summary.

Hip fracture: mortality rate. This updates a previously published measure summary.

Hip osteoarthrosis: hip replacement mortality rate. This updates a previously published measure summary.

Incidental appendectomy: incidental appendectomy among the elderly rate. This updates a previously published measure summary.

Pneumonia: mortality rate. This updates a previously published measure summary.

Institute for Clinical Systems Improvement

Menopause and hormone therapy (HT): collaborative decision-making and management: the percentage of women in menopause who have had a bone mineral density (BMD) measurement a year after cessation of HT. This updates a previously published measure summary.

January 22, 2007

Agency for Healthcare Research and Quality

Abdominal aortic aneurysm (AAA) repair: mortality rate. This updates a previously published measure summary.

Abdominal aortic aneurysm (AAA) repair: volume. This updates a previously published measure summary.

Carotid endarterectomy (CEA): mortality rate. This updates a previously published measure summary.

Carotid endarterectomy (CEA): volume. This updates a previously published measure summary.

Coronary artery bypass graft (CABG): volume. This updates a previously published measure summary.

Coronary artery disease: coronary artery bypass graft (CABG) mortality rate. This updates a previously published measure summary.

Esophageal cancer: esophageal resection mortality rate. This updates a previously published measure summary.

Esophageal resection: volume. This updates a previously published measure summary.

Pancreatic cancer: pancreatic resection mortality rate. This updates a previously published measure summary.

Pancreatic resection: volume. This updates a previously published measure summary.

Percutaneous transluminal coronary angioplasty (PTCA): mortality rate. This updates a previously published measure summary.

Percutaneous transluminal coronary angioplasty (PTCA): volume. This updates a previously published measure summary.

January 15, 2007

American Medical Directors Association

Pressure ulcers: percentage of patients in facility admitted with a pressure ulcer.

British Medical Association

Heart failure: the percentage of patients with a current diagnosis of heart failure due to left ventricular dysfunction (LVD) who are currently treated with angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB), who can tolerate therapy and for whom there is no contraindication.

Heart failure: the percentage of patients with a diagnosis of heart failure (diagnosed after 1 April 2006) which has been confirmed by an echocardiogram or by specialist assessment.

Heart failure: the practice can produce a register of patients with heart failure.

Hypertension: the percentage of patients with hypertension in whom the last blood pressure (measured in the previous 9 months) is 150/90 or less.

Hypertension: the percentage of patients with hypertension in whom there is a record of the blood pressure in the previous 9 months.

Hypertension: the practice can produce a register of patients with established hypertension.

January 8, 2007

Institute for Clinical Systems Improvement

Heart failure in adults: percentage of adult heart failure patients to whom (or to their caregivers) written or verbal instructions or educational material are given during the clinic visit, addressing one or more of the following: activity level, diet, medications, follow-up appointment, weight monitoring, and what to do if symptoms worsen (primary care and outpatient cardiology).

Heart failure in adults: percentage of adult heart failure patients who are current smokers who were given smoking cessation advice or counseling at the last clinic visit (primary care and outpatient cardiology).

Heart failure in adults: percentage of adult heart failure patients who are non-smokers (primary care and outpatient cardiology).

Heart failure in adults: percentage of adult heart failure patients who have ever had left ventricular systolic dysfunction (LVSD) and met the following (for which they are eligible) at their last clinic visit: prescribed or were taking angiotensin-converting enzyme inhibitor/angiotensin receptor blockers (ACEI/ARB), prescribed or were on beta blocker therapy, non-smoker (primary care and outpatient cardiology).

Heart failure in adults: percentage of adult heart failure patients with documentation that left ventricular function (LVF) was assessed or will be assessed (primary care and outpatient cardiology).

Heart failure in adults: percentage of adult patients with a primary diagnosis of heart failure discharged home with written instructions or educational material given to the patient or his or her caregiver at discharge or during the hospital stay, addressing all of the following: activity level, diet, discharge medications, follow-up appointment, weight monitoring, and what to do if symptoms worsen.

Heart failure in adults: percentage of adult patients with a primary diagnosis of heart failure who are current smokers who are given smoking cessation advice or counseling during the hospital stay or at discharge.

Heart failure in adults: percentage of adult patients with a primary diagnosis of heart failure who are re-admitted for heart failure within 30 days of discharge.

Heart failure in adults: percentage of adult patients with a primary diagnosis of heart failure who have left ventricular systolic dysfunction (LVSD) and who do not have a contraindication to taking beta-blockers, who are prescribed beta-blocker therapy at hospital discharge.

Heart failure in adults: percentage of adult patients with a primary diagnosis of heart failure who have left ventricular systolic dysfunction (LVSD) and who do not have contraindications to taking both angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARBs), who are prescribed an ACEI or an ARB at hospital discharge.

Heart failure in adults: percentage of adult patients with a primary diagnosis of heart failure with documentation in the hospital record that left ventricular function (LVF) was assessed before arrival, during hospitalization, or is planned for after discharge.

January 1, 2007

Agency for Healthcare Research and Quality

Accidental puncture or laceration (provider-level): rate per 1,000 discharges. This updates a previously published measure summary.

Birth trauma-injury to neonate: rate per 1,000 liveborn births. This updates a previously published measure summary.

Obstetric trauma (3rd or 4th degree lacerations): rate per 1,000 Cesarean deliveries. This updates a previously published measure summary.

Obstetric trauma (3rd or 4th degree lacerations): rate per 1,000 instrument-assisted vaginal deliveries. This updates a previously published measure summary.

Obstetric trauma (3rd or 4th degree lacerations): rate per 1,000 vaginal deliveries without instrument assistance. This updates a previously published measure summary.

Postoperative pulmonary embolism or deep vein thrombosis: rate per 1,000 surgical discharges with an operating room procedure. This updates a previously published measure summary.

Postoperative respiratory failure: rate per 1,000 elective surgical discharges with an operating room procedure. This updates a previously published measure summary.

Postoperative sepsis: rate per 1,000 elective surgery discharges with an operating room procedure and a length of stay of 4 days or more. This updates a previously published measure summary.

Postoperative wound dehiscence (provider-level): rate of reclosure of postoperative disruption of abdominal wall per 1,000 cases of abdominopelvic surgery. This updates a previously published measure summary.

Transfusion reaction (provider-level): rate per 1,000 discharges. This updates a previously published measure summary.

 

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