Performance Measures:
Measures We Do Not Support
- Health Plan
- Integrated Delivery System
Heart Failure Admission Rate (PQI 8)
INACTIVE REVIEW: This measure review is older than five years.
Admissions with a principal diagnosis of heart failure per 100,000 populations, ages 18 years and older. Excludes cardiac procedure admissions, obstetric admissions, and transfers from other institutions. NOTE: The software provides the rate per population. However, common practice reports the measure as per 100,000 population. The user must multiply the rate obtained from the software by 100,000 to report admissions per 100,000.
Date Reviewed: November 7, 2015
- Group/Practice
- Individual Clinician
Management of Neuropsychiatric Symptoms
Percentage of patients, regardless of age, with a diagnosis of dementia who have one or more neuropsychiatric symptoms who received or were recommended to receive an intervention for neuropsychiatric symptoms within a 12 month period
Date Reviewed: November 19, 2017
- Group/Practice
- Individual Clinician
Pain Assessment and Follow-up
Percentage of visits for patients aged 18 years and older with documentation of a pain assessment using a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present.
Date Reviewed: November 19, 2017
- Group/Practice
- Individual Clinician
Discussion and Shared Decision Making Surrounding Treatment Options
Percentage of patients aged 18 years and older with a diagnosis of hepatitis C with whom a physician or other qualified healthcare professional reviewed the range of treatment options appropriate to their genotype and demonstrated a shared decision making approach with the patient. To meet the measure, there must be documentation in the patient record of a discussion between the physician or other qualified healthcare professional and the patient that includes all of the following: treatment choices appropriate to genotype, risks and benefits, evidence of effectiveness, and patient preferences toward treatment.
Date Reviewed: November 19, 2017
- Group/Practice
- Population: Community, County, or City, Regional and State
Total Cost of Care Population-Based PMPM Index (Cost/Resource use Measure)
INACTIVE REVIEW: This measure review is older than five years.
Total Cost of Care reflects a mix of complicated factors such as patient illness burden, service utilization and negotiated prices.
Total Cost Index (TCI) is a measure of a primary care provider's risk adjusted cost effectiveness at managing the population they care for. TCI includes all costs associated with treating members including professional, facility inpatient and outpatient, pharmacy, lab, radiology, ancillary and behavioral health services.
A Total Cost of Care Index when viewed together with a Resource Use measure provides a more complete picture of population based drivers of health care costs.
Date Reviewed: November 7, 2015
- Individual Clinician
- Health Plan
Use of Opioids from Multiple Providers and at High Dosage in Persons without Cancer
Date Reviewed: April 8, 2019
- Group/Practice
- Individual Clinician
IBD: Preventive Care: Corticosteroid Related Iatrogenic Injury-Bone Loss Assessment
Percentage of patients aged 18 years and older with an inflammatory bowel disease encounter who were prescribed prednisone equivalents greater than or equal to 10 mg/day for 60 or greater consecutive days or a single prescription equating to 600mg prednisone or greater for all fills and were documented for risk of bone loss once during the reporting year or the previous calendar year.
Date Reviewed: November 19, 2017
- Other
GERD - Upper Gastrointestinal Study in Adults with Alarm Symptoms
INACTIVE REVIEW: This measure review is older than five years.
The percentage of adult patients with gastroesophageal reflux disease (GERD) with alarm symptoms who have had an upper gastrointestinal study
Date Reviewed: November 18, 2013
- Group/Practice
- Individual Clinician
HIV/AIDS: Adolescent and Adult Patients who are Prescribed Potent Antiretroviral Therapy
Percentage of patients with a diagnosis of HIV/AIDS, with at least two visits during the measurement year, with at least 90 days between each visit: aged 13 years and older who have a history of a CD4 count less than or equal to 500 cells/mm3; aged 13 years and older who have a history of an AIDS-defining illness, regardless of CD4 count; or who are pregnant, regardless of CD4 count or age, who were prescribed potent antiretroviral therapy
Date Reviewed: July 26, 2014
- Facility
Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate Following Coronary Artery Bypass Graft Surgery
INACTIVE REVIEW: This measure review is older than five years.
The measure estimates a hospital-level risk-standardized mortality rate for patients 18 years and older discharged from the hospital following a qualifying isolated CABG procedure. Mortality is defined as death from any cause within 30 days of the procedure date of an index CABG admission. The measure was developed using Medicare FFS patients 65 years and older and was tested in all-payer patients 18 years and older. An index admission is the hospitalization for a qualifying isolated CABG procedure considered for the readmission outcome.
Date Reviewed: November 7, 2015
- Individual Clinician
- Population: Regional and State
Use of Pharmacotherapy for Opioid Use Disorder
Date Reviewed: April 8, 2019
- Facility
Post-Discharge Evaluation for Heart Failure Patients
Patients who receive a re-evaluation for symptoms worsening and treatment compliance by a program team member within 72 hours after inpatient discharge.
Date Reviewed: November 7, 2015
- Group/Practice
- Individual Clinician
Osteoarthritis: Function and Pain Assessment
Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis (OA) with assessment for function and pain.
Date Reviewed: November 19, 2017
- Group/Practice
- Individual Clinician
Ischemic Vascular Disease: All or None Outcome Measure
The IVD All-or-None Measure is one outcome measure (optimal control). The measure contains four goals. All four goals within a measure must be reached in order to meet that measure. The numerator for the all-or-none measure should be collected from the organization's total IVD denominator. All-or-None Outcome Measure (Optimal Control) - Using the IVD denominator optimal results include: Most recent blood pressure (BP) measurement is less than 140/90 mm Hg -- And Most recent tobacco status is Tobacco Free -- And Daily Aspirin or Other Antiplatelet Unless Contraindicated -- And Statin Use
Date Reviewed: November 19, 2017
- Group/Practice
- Individual Clinician
Adult Kidney Disease: Patients on Erythropoiesis-Stimulating Agent-Hemoglobin Level > 12.0 g/dL
INACTIVE REVIEW: This measure review is older than five years.
Percentage of calendar months within a 12-month period during which a Hemoglobin is measured for patients aged 18 years and older with a diagnosis of advanced CKD (stage 4 or 5, not receiving RRT) or ESRD (who are on hemodialysis or peritoneal dialysis) who are also receiving ESA therapy and have a Hemoglobin Level > 12.0 g/dL
Date Reviewed: November 23, 2013
- Group/Practice
- Individual Clinician
Zoster (Shingles) Vaccination
The percentage of patients 50 years of age and older who have a Varicella Zoster (shingles) vaccination.
Date Reviewed: November 4, 2018
- Group/Practice
- Individual Clinician
HCV Genotype Testing Prior to Treatment
Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving antiviral treatment for whom HCV genotype testing was performed prior to initiation of antiviral treatment (paired with NQF 0395)
Date Reviewed: July 26, 2014
- Group/Practice
- Individual Clinician
Glucocorticoid Management
Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have been assessed for glucocorticoid use and, for those on prolonged doses of prednisone >= 10 mg daily (or equivalent) with improvement or no change in disease activity, documentation of glucocorticoid management plan within 12 months.
Date Reviewed: November 19, 2017
- Group/Practice
- Individual Clinician
Dementia: Functional Status Assessment
Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of functional status is performed and the results reviewed at least once within a 12 month period
Date Reviewed: November 19, 2017
- Individual Clinician
- Facility
Safe Use of Opioids-Concurrent Prescribing
Date Reviewed: April 8, 2019
- Facility
Hospital 30-Day, all-cause, risk standardized readmission rate following heart failure hospitalization
The measure estimates a hospital-level risk-standardized readmission rate (RSRR) for patients discharged from the hospital with a principal diagnosis of heart failure (HF). The outcome is defined as unplanned readmission for any cause within 30 days of the discharge date for the index admission. A specified set of planned readmissions do not count as readmissions. The target population is patients 18 and over. CMS annually reports the measure for patients who are 65 years or older and are either enrolled in fee-for-service (FFS) Medicare and hospitalized in non-federal hospitals or are hospitalized in Veterans Health Administration (VA) facilities.
Date Reviewed: November 7, 2015
- Group/Practice
- Individual Clinician
Tuberculosis (TB) Prevention for Patients with Psoriasis, Psoriatic Arthritis, and Rheumatoid Arthritis Patients on a Biological Immune Response Modifier
Percentage of patients whose providers are ensuring active tuberculosis prevention either through yearly negative standard tuberculosis screening tests or are reviewing the patient’s history to determine if they have had appropriate management for a recent or prior positive test.
Date Reviewed: November 4, 2018
- Group/Practice
- Individual Clinician
HIV/AIDS: Medical Visit
INACTIVE REVIEW: This measure review is older than five years.
Percentage of patients, regardless of age, with a diagnosis of HIV/AIDS, with at least two medical visits during the measurement year, with a minimum of 90 and 180 days between each visit
Date Reviewed: July 26, 2014
- Group/Practice
- Individual Clinician
Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Surgery Patients
Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in asymptomatic, low coronary heart disease (CHD) risk patients 18 years and older for initial detection and risk assessment.
Date Reviewed: November 19, 2017
- Group/Practice
- Individual Clinician
Hepatitis C: Counseling Regarding Use of Contraception Prior to Antiviral Treatment
Date Reviewed: July 26, 2014
- Individual Clinician
Closing the Referral Loop: Receipt of the Specialist Report
Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred
Date Reviewed: July 21, 2018
- Group/Practice
- Individual Clinician
Assessment and Classification of Disease Prognosis
INACTIVE REVIEW: This measure review is older than five years.
Percentage of patients 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease prognosis at least once within 12 months.
Date Reviewed: April 27, 2015
- Health Plan
- Integrated Delivery System
Asthma Medication Ratio
INACTIVE REVIEW: This measure review is older than five years.
The percentage of patients who have a medication ratio of controller medications to total asthma medications of 0.50 or greater during the measurement year.
Date Reviewed: July 26, 2015
- Group/Practice
- Individual Clinician
Hepatitis C Ribonucleic Acid (RNA) Testing Before Initiating Treatment
INACTIVE REVIEW: This measure review is older than five years.
Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving antiviral treatment for whom quantitative HCV RNA testing was performed within 6 months prior to initiation of antiviral treatment (paired with NQF 0396)
Date Reviewed: July 26, 2014
- Individual Clinician
Dementia: Screening for Depressive Symptoms
INACTIVE REVIEW: This measure review is older than five years.
Percentage of patients, regardless of age, with a diagnosis of dementia who were screened for depressive symptoms within a 12 month period
Date Reviewed: April 7, 2014
- Group/Practice
- Health Plan
- Individual Clinician
- Population: Community, County, or City, Regional and State
Proportion of Patients with a Chronic Condition that have a Potentially Avoidable Complication during a Calendar Year
Percent of adult population aged 18+ years who were identified as having at least one of the following six chronic conditions: Asthma, Chronic Obstructive Pulmonary Disease (COPD), Coronary Artery Disease (CAD), Heart Failure (HF), Hypertension (HTN), or Diabetes Mellitus (DM), were followed for at least one-year, and had one or more potentially avoidable complications (PACs) during the most recent 12 months. Please reference attached document labeled NQF_Chronic_Care_PACs_01_24_17.xls, in the tabs labeled PACs I-9 & I-10 for a list of code definitions of PACs relevant to each of the above chronic conditions.
We define PACs as one of two types:
(1) Type 1 PACs - PACs related to the index condition: Patients are considered to have a PAC, if they receive services during the episode time window for any of the complications directly related to the chronic condition, such as for acute exacerbation of the index condition, respiratory insufficiency in patients with Asthma or COPD, hypotension or fluid and electrolyte disturbances in patients with CAD, HF or diabetes etc.
(2) Type 2 PACs - PACs related to Patient Safety or broader System Failures: Patients are also considered to have a PAC, if they receive services during the episode time window for any of the complications related to patient safety or health system failures such as for sepsis, infections, phlebitis, deep vein thrombosis, pressure sores etc.
Date Reviewed: July 21, 2018
- Group/Practice
- Individual Clinician
Hepatitis C: Counseling Regarding Risk of Alcohol Consumption
INACTIVE REVIEW: This measure review is older than five years.
Percentage of patients aged 18 years and older with a diagnosis of hepatitis C who were counseled regarding the risks of alcohol consumption at least once within the 12 month reporting period
Date Reviewed: July 26, 2014
- Population: Community, County, or City, Regional and State
Dehydration Admission Rate (PQI 10)
Admissions with a principal diagnosis of dehydration per 100,000 population, ages 18 years and older. Excludes obstetric admissions and transfers from other institutions.
[NOTE: The software provides the rate per population. However, common practice reports the measure as per 100,000 population. The user must multiply the rate obtained from the software by 100,000 to report admissions per 100,000 population.]
Date Reviewed: July 21, 2018
- Group/Practice
- Individual Clinician
Person-Centered Primary Care Measure PRO-PM (PCPCM PRO-PM)
The Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM) uses the PCPCM PROM (a comprehensive and parsimonious set of 11 patient-reported items) to assess the broad scope of primary care. Unlike other primary care measures, the PCPCM PRO-PM measures the high value aspects of primary care based on a patient’s relationship with the provider or practice. Patients identify the PCPCM PROM as meaningful and able to communicate the quality of their care to their clinicians and/or care team. The items within the PCPCM PROM are based on extensive stakeholder engagement and comprehensive reviews of the literature.
Date Reviewed: April 1, 2021
- Health Plan
- Population: Regional and State
Non-Diabetic Nephropathy - Use of ACE Inhibitor or ARB Therapy
INACTIVE REVIEW: This measure review is older than five years.
The percentage of patients aged 18 years and older with proteinuria who are taking an ACE inhibitor or ARB
Date Reviewed: November 23, 2013
- Individual Clinician
- Integrated Delivery System
INR for Individuals Taking Warfarin and Interacting Anti-Infective Medications
Date Reviewed: April 8, 2019
- Group/Practice
- Individual Clinician
Chlamydia Screening and Follow-up
INACTIVE REVIEW: This measure review is older than five years.
The percentage of female adolescents 18 years of age who had a chlamydia screening test with proper follow-up
Date Reviewed: November 7, 2015
- Facility
Severe Sepsis and Septic Shock: Management Bundle
This measure focuses on adults 18 years and older with a diagnosis of severe sepsis or septic shock. Consistent with Surviving Sepsis Campaign guidelines, the measure contains several elements, including measurement of lactate, obtaining blood cultures, administering broad spectrum antibiotics, fluid resuscitation, vasopressor administration, reassessment of volume status and tissue perfusion, and repeat lactate measurement. As reflected in the data elements and their definitions, these elements should be performed in the early management of severe sepsis and septic shock.
Date Reviewed: July 21, 2018
- Group/Practice
- Individual Clinician
Adult Major Depressive Disorder (MDD): Comprehensive Depression Evaluation: Diagnosis and Severity
INACTIVE REVIEW: This measure review is older than five years.
Percentage of patients aged 18 years and older with a diagnosis or recurrent episode of major depressive disorder (MDD) with evidence that they met the DSM-IV criteria for MDD AND for whom there is an assessment of depression severity during the visit in which a new diagnosis or recurrent episode was identified.
Date Reviewed: April 27, 2015
- Group/Practice
- Individual Clinician
Stroke and Stroke Rehabilitation: Rehabilitation Services Ordered
INACTIVE REVIEW: This measure review is older than five years.
Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or intracranial hemorrhage for whom occupational, physical, or speech rehabilitation services were ordered at or prior to inpatient discharge OR documentation that no rehabilitation services are indicated at or prior to inpatient discharge
Date Reviewed: April 7, 2014
- Group/Practice
- Individual Clinician
Referral to Otologic Evaluation for Patients with Acute or Chronic Dizziness
Percentage of patients aged birth and older referred to a physician (preferably a physician specially trained in disorders of the ear) for an otologic evaluation subsequent to an audiologic evaluation after presenting with acute or chronic dizziness.
Date Reviewed: November 19, 2017
- Group/Practice
- Individual Clinician
Elder Maltreatment Screen and Follow-up Plan
Percentage of patients aged 65 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening tool on the date of encounter AND a documented follow-up plan on the date of the positive screen.
Date Reviewed: November 19, 2017
- Group/Practice
- Individual Clinician
Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older
Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months.
Date Reviewed: November 19, 2017
- Individual Clinician
- Integrated Delivery System
Risk-Standardized Acute Admission Rates for Patients with Multiple Chronic Conditions
Date Reviewed: April 8, 2019
- Group/Practice
- Individual Clinician
Quality of Life Assessment for Patients with Primary Headache Disorders
Percentage of patients with a diagnosis of primary headache disorder whose health related quality of life (HRQoL) was assessed with a tool(s) during at least two visits during the 12 month measurement period AND whose health related quality of life score stayed the same or improved.
Date Reviewed: November 19, 2017
- Facility
Hospital 30-day, all cause, unplanned, risk-standardized readmission rate following CABG surgery
INACTIVE REVIEW: This measure review is older than five years.
The measure estimates a hospital-level risk-standardized readmission rate, defined as unplanned readmission for any cause within 30 days from the date of discharge of the index CABG procedure, for patients 18 years and older discharged from the hospital after undergoing a qualifying isolated CABG procedure. The measure was developed using Medicare FFS patients 65 years and older and was tested in all-payer patients 18 years and older. An index admission is the hospitalization for a qualifying isolated CABG procedure considered for the readmission outcome.
Date Reviewed: November 7, 2015
- Individual Clinician
Staging of Dementia
INACTIVE REVIEW: This measure review is older than five years.
Percentage of patients, regardless of age, with a diagnosis of dementia whose severity of dementia was classified as mild, moderate or severe at least once within a 12 month period
Date Reviewed: April 7, 2014
- Group/Practice
Gains in Patient Activation (PAM) Scores at 12 Months
The Patient Activation Measure® (PAM®) is a 10 or 13 item questionnaire that assesses an individual´s knowledge, skill and confidence for managing their health and health care. The measure assesses individuals on a 0-100 scale. There are 4 levels of activation, from low (1) to high (4). The measure is not disease specific, but has been successfully used with a wide variety of chronic conditions, as well as with people with no conditions. The performance score would be the change in score from the baseline measurement to follow-up measurement, or the change in activation score over time for the eligible patients associated with the accountable unit. The outcome of interest is the patient’s ability to self-manage. High quality care should result in gains in ability to selfmanage for most chronic disease patients. The outcome measured is a change in activation over time. The change score would indicate a change in the patient´s knowledge, skills, and confidence for selfmanagement. A positive change would mean the patient is gaining in their ability to manage their health.
A “passing†score for eligible patients would be to show an average net 3-point PAM score increase in a 6-12 month period. An “excellent†score for eligible patients would be to show an average net 6-point PAM score increase in a 6-12 month period. An “excellent†score would be for eligible patients to show an average of a 6-point PAM score increase in a 6-12 month period.
Date Reviewed: April 1, 2021
- Individual Clinician
- Health Plan
Potentially Harmful Drug-Disease Interactions in the Elderly
Date Reviewed: April 8, 2019
- Group/Practice
- Individual Clinician
Colonoscopy Interval for Patients with a History of Adenomatous Polyps-Avoidance of Inappropriate Use
Percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of prior adenomatous polyp(s) in previous colonoscopy findings, which had an interval of 3 or more years since their last colonoscopy.
Date Reviewed: January 27, 2022
- Group/Practice
- Individual Clinician
- Integrated Delivery System
- Population: Community, County, or City, Regional and State
HIV/AIDS: Screening for High Risk Sexual Behaviors
INACTIVE REVIEW: This measure review is older than five years.
Percentage of patients, aged 13 years and older, who were screened for high risk sexual behaviors at least once within 12 months.
Date Reviewed: November 7, 2015
- Individual Clinician
Heart Failure: Left Ventricular Ejection Fraction Assessment (Outpatient Setting)
INACTIVE REVIEW: This measure review is older than five years.
Percentage of patients aged 18 years and older with a diagnosis of heart failure for whom the quantitative or qualitative results of a recent or prior (any time in the past) LVEF assessment is documented within a 12 month period
Date Reviewed: November 26, 2014
- Group/Practice
- Individual Clinician
Stroke and Stroke Rehabilitation: Deep Vein Thrombosis (DVT) Prophylaxis for Ischemic Stroke or Intracranial Hemorrhage
INACTIVE REVIEW: This measure review is older than five years.
Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or intracranial hemorrhage who were administered DVT prophylaxis by the end of hospital day two
Date Reviewed: April 7, 2014
- Group/Practice
- Individual Clinician
Adult Kidney Disease: Laboratory Testing (Lipid Profile)
RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.
Percentage of patients aged 18 years and older with a diagnosis of CKD (stage 3, 4 or 5, not receiving Renal Replacement Therapy (RRT)) who had a fasting lipid profile performed at least once within a 12-month period
Date Reviewed: November 23, 2013
- Population: Community, County, or City, Regional and State
Chronic Obstructive Pulmonary Disease (COPD) or Asthma in Older Adults Admission Rate (PQI 05)
INACTIVE REVIEW: This measure review is older than five years.
Admissions with a principal diagnosis of chronic obstructive pulmonary disease (COPD) or asthma per 100,000 population, ages 40 years and older. Excludes obstetric admissions and transfers from other institutions. (NOTE: The software provides the rate per population. However, common practice reports the measure as per 100,000 population. The user must multiply the rate obtained from the software by 100,000 to report admissions per 100,000 population)
Date Reviewed: July 26, 2015
- Individual Clinician
- Health Plan
Use of Opioids at High Dosage in Persons Without Cancer
Date Reviewed: April 8, 2019
- Group/Practice
- Individual Clinician
- Health Plan
Follow-Up After Hospitalization for Mental Illness (FUH)
The percentage of discharges for patients 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had a follow-up visit with a mental health practitioner. Two rates are submitted:
• The percentage of discharges for which the patient received follow-up within 30 days after discharge.
• The percentage of discharges for which the patient received follow-up within 7 days after discharge.
Date Reviewed: April 1, 2021
- Facility
Hospital 30-day, all-cause, risk standardized readmission rate following acute MI hospitalization
INACTIVE REVIEW: This measure review is older than five years.
The measure estimates a hospital-level 30-day risk-standardized readmission rate for patients discharged from the hospital with a principal diagnosis of acute MI. The outcome is defined as unplanned readmission for any cause within 30 days of the discharge date for the index admission. A specified set of planned readmissions do not count as readmissions. The target population is patients aged 18 years and older. CMS annually reports the measure for individuals who are 65 years and older and are either Medicare FFS beneficiaries hospitalized in non-federal hospitals or patients hospitalized in Department of VA facilities
Date Reviewed: November 7, 2015
- Individual Clinician
- Facility
Excess Days in Acute Care after Hospitalization for Acute Myocardial Infarction (AMI)
Date Reviewed: April 8, 2019
- Health Plan
Controlling High Blood Pressure for People with Serious Mental Illness
RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.
The percentage of patients 18-85 years of age with serious mental illness who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled during the measurement year.
Note: This measure is adapted from an existing health plan measure used in a variety of reporting programs for the general population (NQF #0018: Controlling High Blood Pressure). It was originally endorsed in 2009 and is owned and stewarded by NCQA. The specifications for the existing measure (Controlling High Blood Pressure NQF #0018) have been updated based on 2013 JNC-8 guideline. NCQA will submit the revised specification for Controlling High Blood Pressure NQF #0018 in the 4th quarter 2014 during NQF’s scheduled measure update period. This measure uses the new specification to be consistent with the current guideline.
Date Reviewed: July 21, 2018
- Group/Practice
- Individual Clinician
Dementia: Caregiver Education Support
Percentage of patients, regardless of age, with a diagnosis of dementia whose caregiver(s) were provided with education on dementia disease management and health behavior changes AND referred to additional resources for support within a 12 month period
Date Reviewed: November 19, 2017
- Group/Practice
- Individual Clinician
HIV/AIDS: HIV RNA Control After Six Months of Potent Antiretroviral Therapy
INACTIVE REVIEW: This measure review is older than five years.
Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS, who had at least two medical visits during the measurement year, with at least 90 days between each visit, who are receiving potent antiretroviral therapy, who have a viral load < 200 copies/mL after at least 6 months of potent antiretroviral therapy
Date Reviewed: July 26, 2014
- Group/Practice
- Individual Clinician
Preventive Care and Screening: Screening for High Blood Pressure and Follow-up Documented
Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated.
Date Reviewed: November 19, 2017
- Individual Clinician
- Facility
Patients Treated with an Opioid who are Given a Bowel Regimen
Date Reviewed: April 8, 2019
- Group/Practice
- Health Plan
- Individual Clinician
Continuity of Pharmacotherapy for Opioid Use Disorder (OUD)
Percentage of adults 18-64 years of age with pharmacotherapy for opioid use disorder (OUD) who have at least 180 days of continuous treatment.
Date Reviewed: November 4, 2018
- Individual Clinician
- Integrated Delivery System
Risk-Standardized Acute Admission Rates for Patients with Diabetes
Date Reviewed: April 8, 2019
- Group/Practice
- Individual Clinician
Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older
"Percentage of patients aged 50 years and older treated for a fracture with documentation of communication, between the physician treating the fracture and the physician or other clinician managing the patient’s on-going care, that a fracture occurred and that the patient was or should be considered for osteoporosis treatment or testing. Note: This measure is submitted by the physician who treats the fracture and who therefore is held accountable for the communication."
Date Reviewed: May 4, 2022
- Individual Clinician
Dementia: Counseling Regarding Risks of Driving
INACTIVE REVIEW: This measure review is older than five years.
Percentage of patients, regardless of age, with a diagnosis of dementia or their caregiver(s) who were counseled regarding the risks of driving and the alternatives to driving at least once within a 12 month period
Date Reviewed: April 7, 2014
- Facility
Hospital 30-day, all cause, risk-standardized mortality rate following acute MI hospitalization for patients 18 and older
INACTIVE REVIEW: This measure review is older than five years.
The measure estimates a hospital 30-day risk-standardized mortality rate. Mortality is defined as death for any cause within 30 days after the date of admission of the index admission, for patients 18 and older discharged from the hospital with a principal diagnosis of acute MI. CMS annually reports the measure for patients who are 65 years or older and are either enrolled in fee-for-service Medicare and hospitalized in non-federal hospitals or are hospitalized in VA facilities
Date Reviewed: November 7, 2015
- Group/Practice
- Individual Clinician
Hepatitis C: HCV RNA Testing at No Greater Than Week 12 of Treatment
Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving antiviral treatment for whom quantitative HCV RNA testing was performed at no greater than 12 weeks from initiation of antiviral treatment
Date Reviewed: July 26, 2014
- Individual Clinician
- Health Plan
Use of Opioids from Multiple Providers in Persons without Cancer
Date Reviewed: April 8, 2019
- Facility
Hospital 30-day, all-cause, risk-standardized mortality rate following heart failure hospitalization for patients 18 and older
INACTIVE REVIEW: This measure review is older than five years.
The measure estimates a hospital 30-day risk-standardized mortality rate. Mortality is defined as death for any cause within 30 days after the date of admission of the index admission, for patients 18 and older discharged from the hospital with a principal diagnosis of HF. CMS annually reports the measure for patients who are 65 years or older and are either enrolled in fee-for-service Medicare and hospitalized in non-federal hospitals or are hospitalized in VA facilities.
Date Reviewed: November 7, 2015
- Facility
- Group/Practice
- Health Plan
- Individual Clinician
- Integrated Delivery System
- Population: Community, County, or City, Regional and State
Adults with Diabetes Mellitus That Had a Serum Creatinine in the Last 12 Reported Months
INACTIVE REVIEW: This measure review is older than five years.
This measure identifies adults with diabetes mellitus that had a serum creatinine test in last 12 reported months
Date Reviewed: November 23, 2013
- Health Plan
- Integrated Delivery System
- Population: Regional and State
Diabetes Monitoring for People with Diabetes and Schizophrenia
The percentage of patients 18 – 64 years of age with schizophrenia and diabetes who had both an LDL-C test and an HbA1c test during the measurement year.
Date Reviewed: July 21, 2018
- Group/Practice
- Individual Clinician
Screening for Hepatocellular Carcinoma in Patients with Cirrhosis
Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C cirrhosis who underwent imaging with either ultrasound, contrast enhanced CT or MRI for hepatocellular carcinoma (HCC) at least once within the 12 month reporting period.
Date Reviewed: November 19, 2017
- Group/Practice
- Individual Clinician
Dementia: Neuropsychiatric Symptom Assessment
Percentage of patients, regardless of age, with a diagnosis of dementia and for whom an assessment of neuropsychiatric symptoms is performed and results reviewed at least once in a 12 month period
Date Reviewed: November 19, 2017
- Health Plan
- Integrated Delivery System
Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Control (<8.0%)
INACTIVE REVIEW: This measure review is older than five years.
The percentage of members 18-75 years of age with diabetes (type 1 and type 2) whose most recent HbA1c level is <8.0% during the measurement year.
Date Reviewed: April 27, 2015
- Group/Practice
- Individual Clinician
Hepatitis C: Hepatitis A Vaccination
Percentage of patients aged 18 years and older with a diagnosis of hepatitis C who have received at least one injection of hepatitis A vaccine, or who have documented immunity to hepatitis A (paired with PQRS 184)
Date Reviewed: July 26, 2014
- Group/Practice
- Individual Clinician
Adult Kidney Disease: Blood Pressure Management
RETIRED REVIEW: This measure has been retired by the measure steward or is not relevant to internal medicine. This measure will not be re-reviewed by the PMC.
Percentage of patient visits for those patients aged 18 years and older with a diagnosis of chronic kidney disease (CKD) (stage 3, 4, or 5, not receiving Renal Replacement Therapy [RRT]) with a blood pressure < 140/90 mmHg OR >= 140/90 mmHg with a documented plan of care.
Date Reviewed: November 19, 2017
- Facility
- Group/Practice
- Individual Clinician
Stroke and Stroke Rehabilitation: Thrombolytic Therapy
INACTIVE REVIEW: This measure review is older than five years.
This measure captures the proportion of acute ischemic stroke patients who arrive at this hospital within 2 hours of time last known well for whom IV t-PA was initiated at this hospital within 3 hours of time last known well
Date Reviewed: April 7, 2014
- Individual Clinician
- Facility
Discharge to Community
Date Reviewed: April 8, 2019
- Group/Practice
- Individual Clinician
Documentation of Current Medications in the Medical Record
Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over the counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency and route of administration.
Date Reviewed: November 19, 2017
- Group/Practice
- Individual Clinician
Diabetic Foot & Ankle Care, Ulcer Prevention-Evaluation of Footwear
Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who were evaluated for proper footwear and sizing.
Date Reviewed: November 19, 2017
- Facility
HIV medical visit frequency
INACTIVE REVIEW: This measure review is older than five years.
Percentage of patients, regardless of age, with a diagnosis of HIV who had at least one medical visit in each 6-month period of the 24-month measurement period with a minimum of 60 days between medical visits. A medical visit is any visit in an outpatient/ambulatory care setting with a nurse practitioner, physician, and/or a physician assistant who provides comprehensive HIV care.
Date Reviewed: November 7, 2015
- Facility
National Healthcare Safety Network Antimicrobial Use Measure
This measure assesses antimicrobial use in hospitals based on medication administration data that hospitals collect electronically at the point of care and report via electronic file submissions to CDC’s National Healthcare Safety Network (NHSN). The antimicrobial use data that are in scope for this measure are antibacterial agents administered to adult and pediatric patients in a specified set of ward and intensive care unit locations: medical, medical/surgical, and surgical wards and units. The measure compares antimicrobial use that the hospitals report with antimicrobial use that is predicted on the basis of nationally aggregated data. The measure is comprised of a discrete set of ratios, Standardized Antimicrobial Administration Ratios (SAARs), each of which summarizes observed-to-predicted antibacterial use for one of 16 antibacterial agent-patient care location combinations. The SAARs are designed to serve as high value targets or high level indicators for antimicrobial stewardship programs (ASPs). SAAR values that are outliers are intended to prompt analysis of possible overuse, underuse, or inappropriate use of antimicrobials, subsequent actions aimed at improving the quality of antimicrobial prescribing, and impact evaluations of ASP interventions.
Date Reviewed: July 21, 2018
- Group/Practice
- Individual Clinician
Hepatitis C: Hepatitis B Vaccination
INACTIVE REVIEW: This measure review is older than five years.
Percentage of patients aged 18 years and older with a diagnosis of hepatitis C who have received at least one injection of hepatitis B vaccine, or who have documented immunity to hepatitis B
Date Reviewed: July 26, 2014
- Group/Practice
- Individual Clinician
Hepatitis C: Antiviral Treatment Prescribed
INACTIVE REVIEW: This measure review is older than five years.
Date Reviewed: July 26, 2014
- Individual Clinician
- Facility
Medication Reconciliation: Number of Unintentional Medication Discrepancies per Patient
Date Reviewed: April 8, 2019
- Group/Practice
- Individual Clinician
Adult Major Depressive Disorder: Coordination of Care of Patients with Specific Comorbid Conditions
INACTIVE REVIEW: This measure review is older than five years.
Percentage of medical records of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) and a specific diagnosed comorbid condition (diabetes, coronary artery disease, ischemic stroke, intracranial hemorrhage, chronic kidney disease [stages 4 or 5], End Stage Renal Disease [ESRD] or congestive heart failure) being treated by another clinician with communication to the clinician treating the comorbid condition.
Date Reviewed: November 19, 2017
- Group/Practice
- Individual Clinician
Sleep Apnea: Assessment of Sleep Symptoms
Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea that includes documentation of an assessment of sleep symptoms, including presence or absence of snoring and daytime sleepiness.
Date Reviewed: November 19, 2017
- Health Plan
BMI Screening and Follow-up for People with Serious Mental Illness
The percentage of patients 18 years and older with a serious mental illness who received a screening for body mass index and follow-up for those people who were identified as obese (a body mass index greater than or equal to 30 kg/m2).
Note: The proposed health plan measure is adapted from an existing provider-level measure for the general population (Preventive Care & Screening: Body Mass Index: Screening and Follow-Up NQF #0421). It is currently stewarded by CMS and used in the Physician Quality Reporting System.
Date Reviewed: July 21, 2018
- Group/Practice
- Individual Clinician
Falls: Screening, Risk-Assessment, and Plan of care to Prevent Future Falls
This is a clinical process measure that assesses falls prevention in older adults. The measure has three rates:
A) Screening for Future Fall Risk: Percentage of patients aged 65 years and older who were screened for future fall risk at least once within 12 months
B) Falls Risk Assessment: Percentage of patients aged 65 years and older with a history of falls who had a risk assessment for falls completed within 12 months
C) Plan of Care for Falls: Percentage of patients aged 65 years and older with a history of falls who had a plan of care for falls documented within 12 months
Date Reviewed: July 21, 2018
- Individual Clinician
- Facility
Excess Days in Acute Care after Hospitalization for Heart Failure
Date Reviewed: April 8, 2019
- Group/Practice
- Individual Clinician
Dementia: Cognitive Assessment
Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12 month period.
Date Reviewed: November 19, 2017
- Facility
- Group/Practice
Gap in HIV Medical Visits
INACTIVE REVIEW: This measure review is older than five years.
Percentage of patients, regardless of age, with a diagnosis of HIV who did not have a medical visit in the last 6 months of the measurement year. A medical visit is any visit in an outpatient/ambulatory care setting with a nurse practitioner, physician, and/or a physician assistant who provides comprehensive HIV care.
Date Reviewed: November 7, 2015
- Group/Practice
- Individual Clinician
Stroke and Stroke Rehabilitation: Screening for Dysphagia
INACTIVE REVIEW: This measure review is older than five years.
Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or intracranial hemorrhage who receive any food, fluids or medication by mouth (PO) for whom a dysphagia screening was performed prior to PO intake in accordance with a dysphagia screening tool approved by the institution in which the patient is receiving care
Date Reviewed: April 7, 2014
- Group/Practice
- Individual Clinician
Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy
Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea who were prescribed positive airway pressure therapy who had documentation that adherence to positive airway pressure therapy was objectively measured.
Date Reviewed: November 4, 2018
- Group/Practice
- Individual Clinician
More Than One CT Scan Within 90 Days for Chronic Sinusitis
Percentage of patients aged 18 years and older with a diagnosis of chronic sinusitis who had more than one CT scan of the paranasal sinuses ordered or received within 90 days after the date of diagnosis.
Date Reviewed: November 19, 2017
- Group/Practice
- Individual Clinician
Diabetic Foot & Ankle Care, Peripheral Neuropathy-Neurological Evaluation
Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who had a neurological examination of their lower extremities within 12 months.
Date Reviewed: November 19, 2017
- Group/Practice
- Individual Clinician
Diabetes: Foot Exam
The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who received a foot exam (visual inspection and sensory exam with mono filament and a pulse exam) during the measurement year.
Date Reviewed: November 19, 2017
- Group/Practice
- Health Plan
- Individual Clinician
- Integrated Delivery System
Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
The percentage of adolescent and adult patients with a new episode of alcohol or other drug (AOD) dependence who received the following.
- Initiation of AOD Treatment. The percentage of patients who initiate treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of the diagnosis.
- Engagement of AOD Treatment. The percentage of patients who initiated treatment and who had two or more additional services with a diagnosis of AOD within 30 days of the initiation visit.
Date Reviewed: July 21, 2018
- Group/Practice
- Health Plan
- Individual Clinician
- Population: Regional and State
Adherence to Antipsychotic Medications for Individuals with Schizophrenia
Percentage of individuals at least 18 years of age as of the beginning of the measurement period with schizophrenia or schizoaffective disorder who had at least two prescription drug claims for antipsychotic medications and had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications during the measurement period (12 consecutive months).
Date Reviewed: November 4, 2018
- Group/Practice
- Individual Clinician
Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low-Risk Surgery Patients
Percentage of stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), or cardiac magnetic resonance (CMR) performed in low risk surgery patients 18 years or older for preoperative evaluation during the 12-month reporting period.
Date Reviewed: November 19, 2017
- Group/Practice
- Individual Clinician
Sleep Apnea: Severity Assessment at Initial Diagnosis
Percentage of patients aged 18 years and older with a diagnosis of obstructive sleep apnea who had an apnea hypopnea index (AHI) or a respiratory disturbance index (RDI) measured at the time of initial diagnosis.
Date Reviewed: November 4, 2018
- Individual Clinician
- Facility
Excess Days in Acute Care after Hospitalization for Pneumonia
Date Reviewed: April 8, 2019