measure name measure id submission method … of mips_benchmark_results... · table 2: mips...

Table 2: MIPS Benchmark Results

Measure_Name Measure_ID Submission_Method Measure_Type Benchmark Decile 3 Decile 4 Decile 5 Decile 6 Decile 7 Decile 8 Decile 9 Decile 10 Topped Out

Diabetes: Hemoglobin A1c Poor Control 1 Claims Outcome Y 35.00 - 25.72 25.71 - 20.32 20.31 - 16.23 16.22 - 13.05 13.04 - 10.01 10.00 - 7.42 7.41 - 4.01 <= 4.00 No

Diabetes: Hemoglobin A1c Poor Control 1 EHR Outcome Y 54.67 - 35.91 35.90 - 25.63 25.62 - 19.34 19.33 - 14.15 14.14 - 9.10 9.09 - 3.34 3.33 - 0.01 0 No

Diabetes: Hemoglobin A1c Poor Control 1 Registry/QCDR Outcome Y 83.10 - 68.19 68.18 - 53.14 53.13 - 40.66 40.65 - 30.20 30.19 - 22.74 22.73 - 16.82 16.81 - 10.33 <= 10.32 No

Colorectal Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN

Category (Regional Lymph Nodes) with Histologic Grade 100 Claims Process Y -- -- -- -- -- -- -- 100 Yes

Colorectal Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN

Category (Regional Lymph Nodes) with Histologic Grade 100 Registry/QCDR Process Y 83.96 - 96.96 96.97 - 99.99 -- -- -- -- -- 100 Yes

Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer

Patients 102 Registry/QCDR Process Y 42.12 - 54.99 55.00 - 71.72 71.73 - 82.13 82.14 - 99.46 99.47 - 99.99 -- -- 100 No

Prostate Cancer: Adjuvant Hormonal Therapy for High Risk Prostate Cancer Patients 104 Registry/QCDR Process Y 77.31 - 80.64 80.65 - 91.19 91.20 - 96.66 96.67 - 98.82 98.83 - 99.99 -- -- 100 Yes

Adult Major Depressive Disorder (MDD): Suicide Risk Assessment 107 EHR Process Y 53.85 - 64.74 64.75 - 70.90 70.91 - 86.68 86.69 - 89.31 89.32 - 92.90 92.91 - 96.54 96.55 - 98.67 >= 98.68 No

Osteoarthritis (OA): Function and Pain Assessment 109 Claims Process Y 80.92 - 94.14 94.15 - 98.67 98.68 - 99.99 -- -- -- -- 100 Yes

Osteoarthritis (OA): Function and Pain Assessment 109 Registry/QCDR Process Y 5.16 - 14.84 14.85 - 37.78 37.79 - 65.33 65.34 - 88.04 88.05 - 97.81 97.82 - 99.99 -- 100 No

Preventive Care and Screening: Influenza Immunization 110 Claims Process Y 22.64 - 31.75 31.76 - 43.13 43.14 - 54.68 54.69 - 66.38 66.39 - 77.47 77.48 - 92.03 92.04 - 99.99 100 No

Preventive Care and Screening: Influenza Immunization 110 EHR Process Y 11.22 - 18.57 18.58 - 24.99 25.00 - 31.84 31.85 - 38.92 38.93 - 47.86 47.87 - 59.99 60.00 - 79.01 >= 79.02 No

Preventive Care and Screening: Influenza Immunization 110 Registry/QCDR Process Y 11.57 - 21.39 21.40 - 31.39 31.40 - 41.31 41.32 - 51.13 51.14 - 62.04 62.05 - 74.27 74.28 - 91.83 >= 91.84 No

Pneumonia Vaccination Status for Older Adults 111 Claims Process Y 39.78 - 51.32 51.33 - 61.67 61.68 - 70.47 70.48 - 77.77 77.78 - 84.49 84.50 - 91.99 92.00 - 99.06 >= 99.07 No

Pneumonia Vaccination Status for Older Adults 111 EHR Process Y 14.13 - 23.25 23.26 - 33.02 33.03 - 43.58 43.59 - 53.96 53.97 - 63.60 63.61 - 74.54 74.55 - 85.52 >= 85.53 No

Pneumonia Vaccination Status for Older Adults 111 Registry/QCDR Process Y 12.24 - 24.02 24.03 - 36.34 36.35 - 48.51 48.52 - 58.95 58.96 - 68.05 68.06 - 77.77 77.78 - 90.19 >= 90.20 No

Breast Cancer Screening 112 Claims Process Y 38.46 - 48.01 48.02 - 55.67 55.68 - 62.78 62.79 - 69.41 69.42 - 77.18 77.19 - 87.87 87.88 - 98.52 >= 98.53 No

Breast Cancer Screening 112 EHR Process Y 12.41 - 22.21 22.22 - 32.30 32.31 - 40.86 40.87 - 47.91 47.92 - 55.25 55.26 - 63.06 63.07 - 73.22 >= 73.23 No

Breast Cancer Screening 112 Registry/QCDR Process Y 14.49 - 24.52 24.53 - 35.70 35.71 - 46.01 46.02 - 55.06 55.07 - 63.67 63.68 - 74.06 74.07 - 87.92 >= 87.93 No

Colorectal Cancer Screening 113 Claims Process Y 29.50 - 42.36 42.37 - 53.84 53.85 - 64.40 64.41 - 75.40 75.41 - 84.67 84.68 - 93.13 93.14 - 99.99 100 No

Colorectal Cancer Screening 113 EHR Process Y 7.35 - 15.97 15.98 - 24.66 24.67 - 33.45 33.46 - 44.39 44.40 - 56.19 56.20 - 67.91 67.92 - 82.28 >= 82.29 No

Colorectal Cancer Screening 113 Registry/QCDR Process Y 10.08 - 20.68 20.69 - 32.73 32.74 - 45.20 45.21 - 55.95 55.96 - 66.31 66.32 - 77.01 77.02 - 88.14 >= 88.15 No

Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis 116 Registry/QCDR Process Y 23.19 - 31.47 31.48 - 63.74 63.75 - 99.99 -- -- -- -- 100 Yes

Diabetes: Eye Exam 117 Claims Process Y 86.36 - 97.77 97.78 - 99.99 -- -- -- -- -- 100 Yes

Diabetes: Eye Exam 117 EHR Process Y 50.57 - 80.68 80.69 - 90.05 90.06 - 94.11 94.12 - 96.66 96.67 - 98.57 98.58 - 99.99 -- 100 No

Diabetes: Eye Exam 117 Registry/QCDR Process Y 69.39 - 89.68 89.69 - 95.95 95.96 - 98.72 98.73 - 99.99 -- -- -- 100 Yes

Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or

Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic

Dysfunction (LVEF < 40%) 118 Registry/QCDR Process Y 71.03 - 74.18 74.19 - 76.51 76.52 - 78.94 78.95 - 81.10 81.11 - 83.99 84.00 - 87.79 87.80 - 95.99 >= 96.00 No

Diabetes: Medical Attention for Nephropathy 119 Claims Process Y 61.76 - 73.84 73.85 - 82.49 82.50 - 88.88 88.89 - 93.64 93.65 - 97.21 97.22 - 99.99 -- 100 No

Diabetes: Medical Attention for Nephropathy 119 EHR Process Y 66.67 - 72.91 72.92 - 78.12 78.13 - 82.26 82.27 - 86.12 86.13 - 89.95 89.96 - 93.32 93.33 - 96.63 >= 96.64 No

Diabetes: Medical Attention for Nephropathy 119 Registry/QCDR Process Y 66.24 - 73.41 73.42 - 79.16 79.17 - 83.01 83.02 - 86.95 86.96 - 90.47 90.48 - 94.51 94.52 - 99.70 >= 99.71 No

Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation 12 Claims Process Y 99.01 - 99.99 -- -- -- -- -- -- 100 Yes

Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation 12 EHR Process Y 73.33 - 82.41 82.42 - 87.39 87.40 - 90.90 90.91 - 94.16 94.17 - 96.57 96.58 - 98.25 98.26 - 99.57 >= 99.58 No

Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation 12 Registry/QCDR Process Y 95.07 - 98.10 98.11 - 99.35 99.36 - 99.99 -- -- -- -- 100 Yes

Adult Kidney Disease: Laboratory Testing (Lipid Profile) 121 Registry/QCDR Process Y 20.00 - 34.26 34.27 - 45.70 45.71 - 58.96 58.97 - 69.48 69.49 - 78.60 78.61 - 90.15 90.16 - 99.99 100 No

Adult Kidney Disease: Blood Pressure Management 122 Registry/QCDR Outcome Y 60.62 - 67.49 67.50 - 75.46 75.47 - 87.87 87.88 - 94.33 94.34 - 96.35 96.36 - 97.77 97.78 - 99.74 >= 99.75 No

Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy - Neurological

Evaluation 126 Registry/QCDR Process Y 10.34 - 18.46 18.47 - 28.94 28.95 - 41.66 41.67 - 60.23 60.24 - 75.20 75.21 - 89.89 89.90 - 99.99 100 No

Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention - Evaluation of

Footwear 127 Registry/QCDR Process Y 4.26 - 11.10 11.11 - 22.80 22.81 - 39.99 40.00 - 61.69 61.70 - 79.56 79.57 - 93.74 93.75 - 99.99 100 No

Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan 128 Claims Process Y 41.33 - 45.76 45.77 - 51.46 51.47 - 66.43 66.44 - 90.09 90.10 - 98.60 98.61 - 99.99 -- 100 No

Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan 128 EHR Process Y 28.73 - 31.80 31.81 - 34.45 34.46 - 37.23 37.24 - 40.19 40.20 - 43.64 43.65 - 48.75 48.76 - 68.18 >= 68.19 No

Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan 128 Registry/QCDR Process Y 39.80 - 45.63 45.64 - 50.91 50.92 - 56.68 56.69 - 64.88 64.89 - 75.81 75.82 - 87.12 87.13 - 97.33 >= 97.34 No

Documentation of Current Medications in the Medical Record 130 Claims Process Y 96.11 - 98.73 98.74 - 99.64 99.65 - 99.99 -- -- -- -- 100 Yes

Documentation of Current Medications in the Medical Record 130 EHR Process Y 76.59 - 87.88 87.89 - 92.73 92.74 - 95.35 95.36 - 97.08 97.09 - 98.27 98.28 - 99.12 99.13 - 99.75 >= 99.76 Yes

Documentation of Current Medications in the Medical Record 130 Registry/QCDR Process Y 61.27 - 82.11 82.12 - 91.71 91.72 - 96.86 96.87 - 99.30 99.31 - 99.99 -- -- 100 Yes

Pain Assessment and Follow-Up 131 Claims Process Y 75.66 - 95.78 95.79 - 99.33 99.34 - 99.99 -- -- -- -- 100 Yes

Pain Assessment and Follow-Up 131 Registry/QCDR Process Y 8.91 - 26.13 26.14 - 50.11 50.12 - 72.57 72.58 - 91.42 91.43 - 99.02 99.03 - 99.99 -- 100 No

Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan 134 Claims Process Y 11.54 - 30.67 30.68 - 62.08 62.09 - 94.03 94.04 - 99.45 99.46 - 99.99 -- -- 100 No

Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan 134 EHR Process Y 1.22 - 2.93 2.94 - 5.93 5.94 - 11.09 11.10 - 17.87 17.88 - 30.29 30.30 - 51.32 51.33 - 72.63 >= 72.64 No

Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan 134 Registry/QCDR Process Y 2.01 - 5.26 5.27 - 14.88 14.89 - 32.90 32.91 - 50.42 50.43 - 64.99 65.00 - 85.25 85.26 - 99.99 100 No

Melanoma: Continuity of Care - Recall System 137 Registry/QCDR Structure Y 53.73 - 75.75 75.76 - 88.45 88.46 - 98.07 98.08 - 99.99 -- -- -- 100 No


Melanoma: Coordination of Care 138 Registry/QCDR Process Y 35.19 - 66.66 66.67 - 88.88 88.89 - 96.54 96.55 - 99.99 -- -- -- 100 Yes

Age-Related Macular Degeneration (AMD): Dilated Macular Examination 14 Claims Process Y -- -- -- -- -- -- -- 100 Yes

Age-Related Macular Degeneration (AMD): Dilated Macular Examination 14 Registry/QCDR Process Y 31.01 - 55.12 55.13 - 77.24 77.25 - 91.17 91.18 - 98.18 98.19 - 99.99 -- -- 100 No

Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement 140 Claims Process Y 97.50 - 99.99 -- -- -- -- -- -- 100 Yes

Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement 140 Registry/QCDR Process Y 32.26 - 48.38 48.39 - 65.54 65.55 - 78.94 78.95 - 89.99 90.00 - 97.43 97.44 - 99.99 -- 100 No

Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15%

OR Documentation of a Plan of Care 141 Claims Process Y -- -- -- -- -- -- -- 100 Yes

Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15%

OR Documentation of a Plan of Care 141 Registry/QCDR Process Y 78.95 - 93.68 93.69 - 98.03 98.04 - 99.75 99.76 - 99.99 -- -- -- 100 Yes

Oncology: Medical and Radiation - Pain Intensity Quantified 143 EHR Process Y -- -- -- -- -- -- -- 100 Yes

Oncology: Medical and Radiation - Pain Intensity Quantified 143 Registry/QCDR Process Y 35.53 - 76.18 76.19 - 82.13 82.14 - 90.20 90.21 - 96.76 96.77 - 99.99 -- -- 100 No

Oncology: Medical and Radiation - Plan of Care for Pain 144 Registry/QCDR Process Y 33.64 - 48.19 48.20 - 66.91 66.92 - 78.41 78.42 - 85.83 85.84 - 99.11 99.12 - 99.99 -- 100 No

Radiology: Exposure Time Reported for Procedures Using Fluoroscopy 145 Claims Process Y 69.33 - 83.10 83.11 - 89.99 90.00 - 93.80 93.81 - 96.13 96.14 - 97.82 97.83 - 99.77 99.78 - 99.99 100 No

Radiology: Exposure Time Reported for Procedures Using Fluoroscopy 145 Registry/QCDR Process Y 67.86 - 77.99 78.00 - 84.61 84.62 - 89.77 89.78 - 93.41 93.42 - 96.66 96.67 - 99.59 99.60 - 99.99 100 No

Radiology: Inappropriate Use of "Probably Benign" Assessment Category in

Mammography Screening 146 Claims Process Y 0.31 - 0.01 -- -- -- -- -- -- 0 Yes

Radiology: Inappropriate Use of "Probably Benign" Assessment Category in

Mammography Screening 146 Registry/QCDR Process Y 4.77 - 2.75 2.74 - 1.25 1.24 - 0.52 0.51 - 0.15 0.14 - 0.01 -- -- 0 Yes

Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing

Bone Scintigraphy 147 Claims Structure Y 50.00 - 65.37 65.38 - 77.77 77.78 - 86.95 86.96 - 93.74 93.75 - 96.96 96.97 - 99.99 -- 100 No

Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing

Bone Scintigraphy 147 Registry/QCDR Structure Y 59.52 - 71.10 71.11 - 83.09 83.10 - 91.66 91.67 - 96.54 96.55 - 99.33 99.34 - 99.99 -- 100 No

Falls: Risk Assessment 154 Claims Process Y 88.89 - 98.75 98.76 - 99.99 -- -- -- -- -- 100 Yes

Falls: Risk Assessment 154 Registry/QCDR Process Y 7.81 - 19.99 20.00 - 38.12 38.13 - 57.62 57.63 - 84.16 84.17 - 99.82 99.83 - 99.99 -- 100 No

Falls: Plan of Care 155 Claims Process Y 34.78 - 55.55 55.56 - 86.26 86.27 - 99.11 99.12 - 99.99 -- -- -- 100 Yes

Falls: Plan of Care 155 Registry/QCDR Process Y 20.00 - 41.43 41.44 - 62.11 62.12 - 75.44 75.45 - 85.99 86.00 - 93.32 93.33 - 98.07 98.08 - 99.99 100 No

Oncology: Radiation Dose Limits to Normal Tissues 156 Registry/QCDR Process Y 93.10 - 96.76 96.77 - 97.72 97.73 - 99.99 -- -- -- -- 100 Yes

Diabetes: Foot Exam 163 Claims Process Y 37.84 - 54.28 54.29 - 71.87 71.88 - 86.51 86.52 - 96.66 96.67 - 99.99 -- -- 100 No

Diabetes: Foot Exam 163 EHR Process Y 5.31 - 10.90 10.91 - 19.99 20.00 - 29.26 29.27 - 38.77 38.78 - 50.09 50.10 - 62.60 62.61 - 76.16 >= 76.17 No

Diabetes: Foot Exam 163 Registry/QCDR Process Y 6.14 - 14.70 14.71 - 25.57 25.58 - 39.80 39.81 - 55.87 55.88 - 72.21 72.22 - 86.43 86.44 - 98.03 >= 98.04 No

Coronary Artery Bypass Graft (CABG): Prolonged Intubation 164 Registry/QCDR Outcome Y 12.16 - 10.65 10.64 - 9.29 9.28 - 7.56 7.55 - 6.30 6.29 - 4.97 4.96 - 3.59 3.58 - 1.83 <= 1.82 No

Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate 165 Registry/QCDR Outcome Y -- -- -- -- -- -- -- 0 Yes

Coronary Artery Bypass Graft (CABG): Stroke 166 Registry/QCDR Outcome Y 2.41 - 1.96 1.95 - 1.39 1.38 - 0.88 0.87 - 0.01 -- -- -- 0 Yes

Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure 167 Registry/QCDR Outcome Y 3.70 - 3.04 3.03 - 2.48 2.47 - 1.91 1.90 - 1.38 1.37 - 0.30 0.29 - 0.01 -- 0 Yes

Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration 168 Registry/QCDR Outcome Y 3.60 - 2.79 2.78 - 2.09 2.08 - 1.63 1.62 - 1.25 1.24 - 0.90 0.89 - 0.01 -- 0 Yes

Hemodialysis Vascular Access Decision-Making by Surgeon to Maximize Placement of

Autogenous Arterial Venous (AV) Fistula 172 Claims Process Y 88.54 - 95.44 95.45 - 99.99 -- -- -- -- -- 100 Yes

Preventive Care and Screening: Unhealthy Alcohol Use - Screening 173 Registry/QCDR Process Y 48.93 - 62.39 62.40 - 71.86 71.87 - 80.71 80.72 - 88.21 88.22 - 94.43 94.44 - 98.48 98.49 - 99.99 100 No

Rheumatoid Arthritis (RA): Functional Status Assessment 178 Registry/QCDR Process Y 27.99 - 45.95 45.96 - 64.17 64.18 - 74.46 74.47 - 81.36 81.37 - 87.82 87.83 - 92.34 92.35 - 99.71 >= 99.72 No

Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and

Level of Severity of Retinopathy 18 EHR Process Y 31.69 - 41.32 41.33 - 49.99 50.00 - 56.97 56.98 - 64.17 64.18 - 70.58 70.59 - 76.97 76.98 - 85.15 >= 85.16 No

Elder Maltreatment Screen and Follow-Up Plan 181 Claims Process Y 7.69 - 91.72 91.73 - 99.27 99.28 - 99.99 -- -- -- -- 100 Yes

Elder Maltreatment Screen and Follow-Up Plan 181 Registry/QCDR Process Y 28.80 - 42.30 42.31 - 51.95 51.96 - 67.46 67.47 - 85.94 85.95 - 97.24 97.25 - 99.65 99.66 - 99.99 100 No

Functional Outcome Assessment 182 Claims Process Y 98.46 - 99.90 99.91 - 99.99 -- -- -- -- -- 100 Yes

Functional Outcome Assessment 182 Registry/QCDR Process Y 94.35 - 97.47 97.48 - 99.20 99.21 - 99.99 -- -- -- -- 100 Yes

Colonoscopy Interval for Patients with a History of Adenomatous Polyps Avoidance of

Inappropriate Use National Quality Strategy Domain: Communication and Care

Coordination 185 Claims Process Y 98.82 - 99.99 -- -- -- -- -- -- 100 Yes

Colonoscopy Interval for Patients with a History of Adenomatous Polyps Avoidance of

Inappropriate Use National Quality Strategy Domain: Communication and Care

Coordination 185 Registry/QCDR Process Y 81.08 - 88.67 88.68 - 93.23 93.24 - 96.19 96.20 - 98.27 98.28 - 99.99 -- -- 100 Yes

Stroke and Stroke Rehabilitation: Thrombolytic Therapy 187 Registry/QCDR Outcome Y 14.55 - 34.99 35.00 - 43.74 43.75 - 52.37 52.38 - 66.66 66.67 - 76.24 76.25 - 96.66 96.67 - 99.99 100 No

Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes

Care 19 Claims Process Y -- -- -- -- -- -- -- 100 Yes


Care 19 EHR Process Y 20.00 - 29.78 29.79 - 38.35 38.36 - 45.70 45.71 - 52.53 52.54 - 60.79 60.80 - 68.80 68.81 - 79.30 >= 79.31 No


Care 19 Registry/QCDR Process Y 36.21 - 59.99 60.00 - 78.56 78.57 - 89.80 89.81 - 96.22 96.23 - 99.99 -- -- 100 No

Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery 191 EHR Outcome Y 86.61 - 91.42 91.43 - 94.43 94.44 - 96.07 96.08 - 97.35 97.36 - 98.30 98.31 - 99.24 99.25 - 99.99 100 No

Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery 191 Registry/QCDR Outcome Y 42.89 - 59.56 59.57 - 83.17 83.18 - 91.52 91.53 - 94.84 94.85 - 96.79 96.80 - 99.25 99.26 - 99.99 100 No

Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional

Surgical Procedures 192 EHR Outcome Y 0.92 - 0.43 0.42 - 0.01 -- -- -- -- -- 0 Yes


Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional

Surgical Procedures 192 Registry/QCDR Outcome Y 1.60 - 0.75 0.74 - 0.24 0.23 - 0.01 -- -- -- -- 0 Yes

Perioperative Temperature Management 193 Claims Outcome Y 92.50 - 95.82 95.83 - 97.64 97.65 - 98.71 98.72 - 99.45 99.46 - 99.99 -- -- 100 Yes

Perioperative Temperature Management 193 Registry/QCDR Outcome Y 98.18 - 99.99 -- -- -- -- -- -- 100 Yes

Oncology: Cancer Stage Documented 194 Registry/QCDR Process Y 5.00 - 9.81 9.82 - 23.88 23.89 - 62.49 62.50 - 83.01 83.02 - 94.86 94.87 - 99.82 99.83 - 99.99 100 No

Radiology: Stenosis Measurement in Carotid Imaging Reports 195 Claims Process Y 78.57 - 87.49 87.50 - 92.49 92.50 - 95.78 95.79 - 97.66 97.67 - 99.62 99.63 - 99.99 -- 100 Yes

Radiology: Stenosis Measurement in Carotid Imaging Reports 195 Registry/QCDR Process Y 82.98 - 90.90 90.91 - 94.49 94.50 - 96.76 96.77 - 98.40 98.41 - 99.99 -- -- 100 Yes

Diabetes: Low Density Lipoprotein (LDL-C) Control (<100 mg/dL) 2 EHR Outcome Y 20.83 - 29.47 29.48 - 35.99 36.00 - 42.44 42.45 - 48.17 48.18 - 54.03 54.04 - 60.33 60.34 - 69.35 >= 69.36 No

Diabetes: Low Density Lipoprotein (LDL-C) Control (<100 mg/dL) 2 Registry/QCDR Outcome Y 0.83 - 1.06 1.07 - 1.35 1.36 - 1.82 1.83 - 2.51 2.52 - 3.53 3.54 - 6.45 6.46 - 25.57 >= 25.58 No

Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 204 Claims Process Y 84.09 - 87.17 87.18 - 89.46 89.47 - 91.29 91.30 - 93.05 93.06 - 94.99 95.00 - 96.76 96.77 - 99.99 100 No

Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 204 EHR Process Y 55.21 - 63.76 63.77 - 69.99 70.00 - 74.99 75.00 - 78.78 78.79 - 81.99 82.00 - 85.03 85.04 - 88.69 >= 88.70 No

Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 204 Registry/QCDR Process Y 68.03 - 75.75 75.76 - 80.76 80.77 - 84.61 84.62 - 87.92 87.93 - 90.94 90.95 - 94.73 94.74 - 99.99 100 No

Perioperative Care: Selection of Prophylactic Antibiotic - First OR Second Generation

Cephalosporin 21 Claims Process Y -- -- -- -- -- -- -- 100 Yes


Cephalosporin 21 Registry/QCDR Process Y 91.17 - 99.10 99.11 - 99.99 -- -- -- -- -- 100 Yes

Perioperative Care: Discontinuation of Prophylactic Parenteral Antibiotics (Non-Cardiac

Procedures) 22 Claims Process Y -- -- -- -- -- -- -- 100 Yes


Procedures) 22 Registry/QCDR Process Y 45.69 - 77.37 77.38 - 97.77 97.78 - 99.99 -- -- -- -- 100 Yes

Melanoma: Overutilization of Imaging Studies in Melanoma 224 Registry/QCDR Process Y -- -- -- -- -- -- -- 100 Yes

Radiology: Reminder System for Screening Mammograms 225 Claims Structure Y 89.85 - 98.64 98.65 - 99.99 -- -- -- -- -- 100 No

Radiology: Reminder System for Screening Mammograms 225 Registry/QCDR Structure Y 99.89 - 99.99 -- -- -- -- -- -- 100 Yes

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 226 Claims Process Y 95.60 - 97.85 97.86 - 99.25 99.26 - 99.99 -- -- -- -- 100 Yes

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 226 EHR Process Y 72.59 - 81.59 81.60 - 86.68 86.69 - 90.15 90.16 - 92.64 92.65 - 94.67 94.68 - 96.58 96.59 - 98.51 >= 98.52 No

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 226 Registry/QCDR Process Y 76.67 - 85.53 85.54 - 89.87 89.88 - 92.85 92.86 - 95.14 95.15 - 97.21 97.22 - 99.10 99.11 - 99.99 100 No

Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL

Patients) 23 Claims Process Y -- -- -- -- -- -- -- 100 Yes

Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL

Patients) 23 Registry/QCDR Process Y 89.74 - 96.66 96.67 - 99.99 -- -- -- -- -- 100 Yes

Controlling High Blood Pressure 236 Claims Process Y 57.69 - 63.44 63.45 - 68.28 68.29 - 72.78 72.79 - 77.06 77.07 - 81.47 81.48 - 86.75 86.76 - 93.42 >= 93.43 No

Controlling High Blood Pressure 236 EHR Process Y 50.00 - 55.39 55.40 - 59.72 59.73 - 63.59 63.60 - 67.38 67.39 - 71.00 71.01 - 75.33 75.34 - 80.89 >= 80.90 No

Controlling High Blood Pressure 236 Registry/QCDR Process Y 51.00 - 58.20 58.21 - 63.56 63.57 - 68.27 68.28 - 72.40 72.41 - 76.69 76.70 - 82.75 82.76 - 91.06 >= 91.07 No

Use of High-Risk Medications in the Elderly 238 EHR Process Y 26.32 - 21.23 21.22 - 15.75 15.74 - 9.40 9.39 - 3.86 3.85 - 0.91 0.90 - 0.01 -- 0 No

Use of High-Risk Medications in the Elderly 238 Registry/QCDR Process Y 20.00 - 15.02 15.01 - 10.54 10.53 - 6.23 6.22 - 2.64 2.63 - 1.00 0.99 - 0.29 0.28 - 0.01 0 No

Weight Assessment and Counseling for Nutrition and Physical Activity for Children and

Adolescents 239 EHR Process Y 25.72 - 28.72 28.73 - 30.38 30.39 - 31.52 31.53 - 32.30 32.31 - 32.80 32.81 - 33.32 33.33 - 34.94 >= 34.95 No

Osteoporosis: Communication with the Physician Managing On-going Care Post-Fracture

of Hip, Spine or Distal Radius for Men and Women Aged 50 Years and Older 24 Claims Process Y 75.00 - 91.29 91.30 - 96.42 96.43 - 99.99 -- -- -- -- 100 Yes

Osteoporosis: Communication with the Physician Managing On-going Care Post-Fracture

of Hip, Spine or Distal Radius for Men and Women Aged 50 Years and Older 24 Registry/QCDR Process Y 8.00 - 10.33 10.34 - 12.49 12.50 - 17.06 17.07 - 21.87 21.88 - 49.99 50.00 - 82.49 82.50 - 99.99 100 No

Childhood Immunization Status 240 EHR Process Y 4.76 - 6.51 6.52 - 9.08 9.09 - 13.00 13.01 - 18.17 18.18 - 23.80 23.81 - 29.32 29.33 - 41.66 >= 41.67 No

Ischemic Vascular Disease (IVD): Complete Lipid Profile and LDL-C Control (<100 mg/dL) 241 EHR Process Y 21.62 - 35.70 35.71 - 46.33 46.34 - 53.95 53.96 - 60.37 60.38 - 66.51 66.52 - 73.39 73.40 - 81.89 >= 81.90 No

Ischemic Vascular Disease (IVD): Complete Lipid Profile and LDL-C Control (<100 mg/dL) 241 Registry/QCDR Process Y 15.56 - 17.74 17.75 - 19.55 19.56 - 22.23 22.24 - 24.76 24.77 - 30.29 30.30 - 34.76 34.77 - 41.75 >= 41.76 No

Coronary Artery Disease (CAD): Symptom Management 242 Registry/QCDR Outcome Y 87.89 - 93.17 93.18 - 95.05 95.06 - 97.23 97.24 - 98.30 98.31 - 99.20 99.21 - 99.99 -- 100 Yes

Barrett's Esophagus 249 Claims Structure Y -- -- -- -- -- -- -- 100 Yes

Barrett's Esophagus 249 Registry/QCDR Structure Y -- -- -- -- -- -- -- 100 Yes

Radical Prostatectomy Pathology Reporting 250 Claims Structure Y -- -- -- -- -- -- -- 100 Yes

Quantitative Immunohistochemical (IHC) Evaluation of Human Epidermal Growth Factor

Receptor 2 Testing (HER2) for Breast Cancer Patients 251 Claims Structure Y -- -- -- -- -- -- -- 100 Yes

Quantitative Immunohistochemical (IHC) Evaluation of Human Epidermal Growth Factor

Receptor 2 Testing (HER2) for Breast Cancer Patients 251 Registry/QCDR Structure Y -- -- -- -- -- -- -- 100 Yes

Image Confirmation of Successful Excision of Image-Localized Breast Lesion 262 Registry/QCDR Process Y -- -- -- -- -- -- -- 100 Yes

Preoperative Diagnosis of Breast Cancer 263 Registry/QCDR Process Y 97.95 - 98.91 98.92 - 99.99 -- -- -- -- -- 100 Yes

Sentinel Lymph Node Biopsy for Invasive Breast Cancer 264 Registry/QCDR Process Y 97.01 - 97.99 98.00 - 98.89 98.90 - 99.99 -- -- -- -- 100 Yes

Biopsy Follow-Up 265 Registry/QCDR Process Y 24.44 - 53.53 53.54 - 78.78 78.79 - 94.99 95.00 - 99.99 -- -- -- 100 Yes

Dementia: Cognitive Assessment 281 EHR Process Y 5.66 - 17.56 17.57 - 30.76 30.77 - 56.25 56.26 - 78.05 78.06 - 88.13 88.14 - 95.55 95.56 - 99.99 100 No


Cataracts: Improvement in Patient's Visual Function within 90 Days Following Cataract

Surgery 303 Registry/QCDR Outcome Y 5.76 - 9.37 9.38 - 23.80 23.81 - 29.87 29.88 - 43.60 43.61 - 56.69 56.70 - 94.33 94.34 - 99.99 100 No

Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery 304 Registry/QCDR Outcome Y 5.32 - 7.68 7.69 - 21.69 21.70 - 26.67 26.68 - 39.60 39.61 - 46.60 46.61 - 83.07 83.08 - 99.99 100 No

Initiation and Engagement of Alcohol and Other Drug Dependence Treatment 305 EHR Process Y 0.71 - 0.94 0.95 - 1.20 1.21 - 2.10 2.11 - 2.49 2.50 - 5.12 5.13 - 6.98 6.99 - 12.05 >= 12.06 No

Cervical Cancer Screening 309 EHR Process Y 8.89 - 15.08 15.09 - 21.79 21.80 - 28.83 28.84 - 36.66 36.67 - 44.99 45.00 - 54.77 54.78 - 68.99 >= 69.00 No

Cervical Cancer Screening 309 Registry/QCDR Process Y 28.95 - 35.91 35.92 - 43.02 43.03 - 45.56 45.57 - 49.25 49.26 - 51.40 51.41 - 53.78 53.79 - 59.23 >= 59.24 No

Chlamydia Screening for Women 310 EHR Process Y 8.33 - 12.86 12.87 - 18.17 18.18 - 24.99 25.00 - 33.32 33.33 - 39.99 40.00 - 49.99 50.00 - 61.53 >= 61.54 No

Chlamydia Screening for Women 310 Registry/QCDR Process Y 6.06 - 7.18 7.19 - 9.08 9.09 - 10.23 10.24 - 11.53 11.54 - 13.78 13.79 - 18.17 18.18 - 20.86 >= 20.87 No

Use of Appropriate Medications for Asthma 311 EHR Process Y 16.67 - 41.02 41.03 - 58.05 58.06 - 69.05 69.06 - 75.48 75.49 - 81.81 81.82 - 87.49 87.50 - 92.97 >= 92.98 No

Use of Imaging Studies for Low Back Pain 312 EHR Process Y 83.12 - 90.47 90.48 - 96.14 96.15 - 99.99 -- -- -- -- 100 Yes

Use of Imaging Studies for Low Back Pain 312 Registry/QCDR Process Y 55.00 - 91.99 92.00 - 99.99 -- -- -- -- -- 100 Yes

Preventive Care and Screening: Cholesterol - Fasting Low Density Lipoprotein (LDL-C) Test

Performed 316A EHR Process Y 3.06 - 10.17 10.18 - 23.74 23.75 - 36.37 36.38 - 47.57 47.58 - 58.51 58.52 - 67.18 67.19 - 77.47 >= 77.48 No


Performed: AND Risk-Stratified Fasting LDL-C 316B EHR Process Y 69.09 - 73.59 73.60 - 76.39 76.40 - 79.05 79.06 - 81.40 81.41 - 84.05 84.06 - 87.49 87.50 - 92.42 >= 92.43 No

Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up

Documented 317 Claims Process Y 42.13 - 50.44 50.45 - 59.06 59.07 - 68.11 68.12 - 78.63 78.64 - 92.67 92.68 - 99.53 99.54 - 99.99 100 No


Documented 317 EHR Process Y 17.90 - 22.55 22.56 - 25.80 25.81 - 28.83 28.84 - 31.69 31.70 - 34.67 34.68 - 38.96 38.97 - 46.26 >= 46.27 No


Documented 317 Registry/QCDR Process Y 24.74 - 35.47 35.48 - 47.87 47.88 - 62.14 62.15 - 71.64 71.65 - 79.36 79.37 - 88.85 88.86 - 98.87 >= 98.88 No

Falls: Screening for Future Fall Risk 318 EHR Process Y 6.33 - 17.92 17.93 - 31.98 31.99 - 47.86 47.87 - 63.81 63.82 - 81.04 81.05 - 90.20 90.21 - 98.49 >= 98.50 No

Falls: Screening for Future Fall Risk 318 Registry/QCDR Process Y 0.11 - 0.11 0.12 - 0.14 0.15 - 0.20 0.21 - 0.28 0.29 - 0.50 0.51 - 55.23 55.24 - 92.20 >= 92.21 No

Stroke and Stroke Rehabilitation: Discharged on Antithrombotic Therapy 32 Claims Process Y 51.16 - 63.63 63.64 - 87.99 88.00 - 96.42 96.43 - 99.99 -- -- -- 100 Yes

Stroke and Stroke Rehabilitation: Discharged on Antithrombotic Therapy 32 Registry/QCDR Process Y 27.17 - 46.29 46.30 - 67.85 67.86 - 80.85 80.86 - 90.90 90.91 - 96.42 96.43 - 99.99 -- 100 No

Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in

Average Risk Patients 320 Claims Process Y 90.00 - 95.44 95.45 - 99.99 -- -- -- -- -- 100 Yes

Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in

Average Risk Patients 320 Registry/QCDR Process Y 81.82 - 90.69 90.70 - 95.44 95.45 - 98.11 98.12 - 99.99 -- -- -- 100 Yes

Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in

Low Risk Surgery Patients 322 Registry/QCDR Efficiency Y 2.67 - 0.54 0.53 - 0.01 -- -- -- -- -- 0 Yes

Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After

Percutaneous Coronary Intervention (PCI) 323 Registry/QCDR Efficiency Y 1.00 - 0.01 -- -- -- -- -- -- 0 Yes

Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic,

Low-Risk Patients 324 Registry/QCDR Efficiency Y 3.38 - 0.79 0.78 - 0.01 -- -- -- -- -- 0 Yes

Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific

Comorbid Conditions 325 Registry/QCDR Process Y 91.30 - 98.50 98.51 - 99.99 -- -- -- -- -- 100 Yes

Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy 326 Claims Process Y 94.09 - 96.85 96.86 - 99.37 99.38 - 99.99 -- -- -- -- 100 Yes

Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy 326 Registry/QCDR Process Y 20.00 - 39.18 39.19 - 52.33 52.34 - 69.56 69.57 - 76.18 76.19 - 82.49 82.50 - 94.33 94.34 - 99.99 100 No

Stroke and Stroke Rehabilitation: Anticoagulant Therapy Prescribed for Atrial Fibrillation

(AF) at Discharge 33 Registry/QCDR Process Y 29.55 - 43.18 43.19 - 55.77 55.78 - 73.75 73.76 - 87.79 87.80 - 95.22 95.23 - 99.99 -- 100 No

Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Appropriate Use) 331 Registry/QCDR Process Y 89.07 - 82.41 82.40 - 71.44 71.43 - 46.46 46.45 - 16.91 16.90 - 0.60 0.59 - 0.01 -- 0 No

Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin Prescribed for Patients with

Acute Bacterial Sinusitis 332 Registry/QCDR Process Y 44.39 - 47.99 48.00 - 51.88 51.89 - 57.57 57.58 - 64.99 65.00 - 72.72 72.73 - 95.99 96.00 - 99.99 100 No

Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse) 333 Registry/QCDR Outcome Y 2.13 - 0.66 0.65 - 0.01 -- -- -- -- -- 0 Yes

Adult Sinusitis: More than One Computerized Tomography (CT) Scan Within 90 Days for

Chronic Sinusitis (Overuse) 334 Registry/QCDR Outcome Y 2.25 - 1.73 1.72 - 1.12 1.11 - 0.01 -- -- -- -- 0 Yes

Tuberculosis Prevention for Psoriasis and Psoriatic Arthritis Patients on a Biological

Immune Response Modifier 337 Registry/QCDR Process Y 6.82 - 16.12 16.13 - 24.13 24.14 - 47.59 47.60 - 90.90 90.91 - 99.99 -- -- 100 No

Screening Colonoscopy Adenoma Detection Rate 343 Registry/QCDR Outcome Y 29.63 - 38.09 38.10 - 41.85 41.86 - 45.70 45.71 - 48.69 48.70 - 56.51 56.52 - 63.40 63.41 - 80.32 >= 80.33 No

Patient-Centered Surgical Risk Assessment and Communication 358 Registry/QCDR Process Y 8.47 - 27.02 27.03 - 78.25 78.26 - 95.23 95.24 - 99.99 -- -- -- 100 Yes

Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized

Nomenclature for Computerized Tomography (CT) Imaging Description 359 Registry/QCDR Process Y -- -- -- -- -- -- -- 100 Yes

Optimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) Images

Available for Patient Follow-up and Comparison Purposes 362 Registry/QCDR Structure Y -- -- -- -- -- -- -- 100 Yes

Optimizing Patient Exposure to Ionizing Radiation: Search for Prior Computed

Tomography (CT) Imaging Studies Through a Secure, Authorized, Media-Free, Shared

Archive 363 Registry/QCDR Structure Y -- -- -- -- -- -- -- 100 Yes

HIV/AIDS: Medical Visit 368 EHR Process Y 45.21 - 53.67 53.68 - 59.99 60.00 - 68.05 68.06 - 74.99 75.00 - 80.99 81.00 - 89.57 89.58 - 96.66 >= 96.67 No

Depression Utilization of the PHQ-9 Tool 371 EHR Process Y 1.38 - 1.95 1.96 - 2.91 2.92 - 4.29 4.30 - 6.81 6.82 - 12.23 12.24 - 21.20 21.21 - 52.62 >= 52.63 No

Depression Utilization of the PHQ-9 Tool 371 Registry/QCDR Process Y 0.27 - 0.34 0.35 - 0.39 0.40 - 0.52 0.53 - 0.60 0.61 - 0.75 0.76 - 0.89 0.90 - 1.43 >= 1.44 No

Hypertension: Improvement in Blood Pressure 373 EHR Outcome Y 6.82 - 9.31 9.32 - 11.70 11.71 - 14.40 14.41 - 17.39 17.40 - 21.44 21.45 - 27.61 27.62 - 39.04 >= 39.05 No

Hypertension: Improvement in Blood Pressure 373 Registry/QCDR Outcome Y 2.39 - 2.93 2.94 - 3.46 3.47 - 3.92 3.93 - 4.71 4.72 - 5.53 5.54 - 6.74 6.75 - 9.99 >= 10 No

Closing the Referral Loop: Receipt of Specialist Report 374 EHR Process Y 2.70 - 6.24 6.25 - 11.46 11.47 - 18.15 18.16 - 25.57 25.58 - 36.95 36.96 - 51.17 51.18 - 71.87 >= 71.88 No

Functional Status Assessment for Knee Replacement 375 EHR Process Y 5.36 - 9.51 9.52 - 9.99 10.00 - 43.95 43.96 - 47.82 47.83 - 54.54 54.55 - 66.04 66.05 - 85.18 >= 85.19 No


Children Who Have Dental Decay or Cavities 378 EHR Outcome Y 0.36 - 0.01 -- -- -- -- -- -- 0 Yes

Primary Caries Prevention Intervention as Offered by Primary Care Providers, including

Dentists 379 EHR Process Y 0.79 - 0.96 0.97 - 1.62 1.63 - 2.03 2.04 - 4.26 4.27 - 6.59 6.60 - 7.88 7.89 - 14.28 >= 14.29 No

HIV/AIDS: RNA Control for Patients with HIV 381 EHR Outcome Y 19.47 - 27.84 27.85 - 33.42 33.43 - 42.85 42.86 - 76.26 76.27 - 84.99 85.00 - 90.31 90.32 - 92.49 >= 92.50 No

Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment 382 EHR Process Y 4.84 - 10.64 10.65 - 16.29 16.30 - 28.56 28.57 - 92.97 92.98 - 98.50 98.51 - 99.33 99.34 - 99.99 100 No

Adherence to Antipsychotic Medications for Individuals with Schizophrenia 383 Registry/QCDR Outcome Y 34.78 - 60.50 60.51 - 72.36 72.37 - 80.54 80.55 - 91.99 92.00 - 99.99 -- -- 100 No

Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior

Capsule Requiring Unplanned Vsitrectomy) 388 Registry/QCDR Outcome Y 0.26 - 0.01 -- -- -- -- -- -- 0 Yes

Cataract Surgery: Difference Between Planned and Final Refraction 389 Registry/QCDR Outcome Y 66.67 - 88.45 88.46 - 94.11 94.12 - 98.09 98.10 - 99.99 -- -- -- 100 No

Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older 39 Claims Process Y 30.77 - 39.54 39.55 - 46.74 46.75 - 53.96 53.97 - 61.89 61.90 - 70.86 70.87 - 82.53 82.54 - 95.87 >= 95.88 No

Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older 39 Registry/QCDR Process Y 13.39 - 16.66 16.67 - 20.39 20.40 - 25.31 25.32 - 33.99 34.00 - 47.94 47.95 - 64.65 64.66 - 82.53 >= 82.54 No

Follow-up After Hospitalization for Mental Illness (FUH) 391 Registry/QCDR Process Y 3.81 - 13.63 13.64 - 17.48 17.49 - 46.63 46.64 - 72.33 72.34 - 99.99 -- -- 100 No

Lung Cancer Reporting (Biopsy/Cytology Specimens) 395 Claims Process Y 91.30 - 97.49 97.50 - 99.99 -- -- -- -- -- 100 Yes

Lung Cancer Reporting (Biopsy/Cytology Specimens) 395 Registry/QCDR Process Y 93.75 - 99.65 99.66 - 99.99 -- -- -- -- -- 100 Yes

Melanoma Reporting 397 Claims Process Y 68.33 - 78.42 78.43 - 95.11 95.12 - 99.99 -- -- -- -- 100 Yes

Melanoma Reporting 397 Registry/QCDR Process Y 47.22 - 92.67 92.68 - 99.99 -- -- -- -- -- 100 Yes

Osteoporosis: Management Following Fracture of Hip, Spine or Distal Radius for Men and

Women Aged 50 Years and Older 40 Claims Process Y 15.00 - 27.99 28.00 - 36.14 36.15 - 49.99 50.00 - 75.30 75.31 - 92.85 92.86 - 99.99 -- 100 No

Osteoporosis: Management Following Fracture of Hip, Spine or Distal Radius for Men and

Women Aged 50 Years and Older 40 Registry/QCDR Process Y 5.00 - 6.95 6.96 - 8.69 8.70 - 16.13 16.14 - 32.78 32.79 - 47.40 47.41 - 65.56 65.57 - 88.88 >= 88.89 No

Hepatitis C: One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk 400 Registry/QCDR Process Y 1.19 - 1.33 1.34 - 1.53 1.54 - 1.71 1.72 - 2.09 2.10 - 2.92 2.93 - 8.32 8.33 - 20.01 >= 20.02 No

Tobacco Use and Help with Quitting Among Adolescents 402 Registry/QCDR Process Y 74.10 - 81.15 81.16 - 87.49 87.50 - 90.37 90.38 - 92.72 92.73 - 95.15 95.16 - 97.50 97.51 - 99.99 100 No

Osteoporosis: Pharmacologic Therapy for Men and Women Aged 50 Years and Older 41 Claims Process Y 33.33 - 40.45 40.46 - 46.66 46.67 - 58.32 58.33 - 74.50 74.51 - 96.45 96.46 - 99.99 -- 100 No

Osteoporosis: Pharmacologic Therapy for Men and Women Aged 50 Years and Older 41 Registry/QCDR Process Y 33.33 - 40.43 40.44 - 46.28 46.29 - 52.77 52.78 - 59.25 59.26 - 66.66 66.67 - 75.58 75.59 - 99.99 100 No

Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) in Patients

with Isolated CABG Surgery 43 Registry/QCDR Process Y 98.17 - 98.69 98.70 - 99.99 -- -- -- -- -- 100 Yes

Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated

CABG Surgery 44 Claims Process Y 96.84 - 99.99 -- -- -- -- -- -- 100 Yes

Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated

CABG Surgery 44 Registry/QCDR Process Y 91.14 - 94.99 95.00 - 97.32 97.33 - 98.87 98.88 - 99.99 -- -- -- 100 Yes

Medication Reconciliation 46 Claims Process Y 96.00 - 98.10 98.11 - 99.99 -- -- -- -- -- 100 Yes

Medication Reconciliation 46 Registry/QCDR Process Y 91.97 - 98.02 98.03 - 99.99 -- -- -- -- -- 100 Yes

Advance Care Plan 47 Claims Process Y 13.68 - 34.57 34.58 - 62.86 62.87 - 86.91 86.92 - 97.10 97.11 - 99.59 99.60 - 99.99 -- 100 No

Advance Care Plan 47 Registry/QCDR Process Y 16.52 - 38.11 38.12 - 59.14 59.15 - 74.99 75.00 - 88.71 88.72 - 96.29 96.30 - 99.17 99.18 - 99.99 100 No

Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in

Women Aged 65 Years and Older 48 Claims Process Y 6.25 - 20.42 20.43 - 64.72 64.73 - 96.76 96.77 - 99.99 -- -- -- 100 Yes

Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in

Women Aged 65 Years and Older 48 Registry/QCDR Process Y 16.31 - 29.03 29.04 - 42.90 42.91 - 57.07 57.08 - 76.52 76.53 - 89.12 89.13 - 96.91 96.92 - 99.99 100 No

Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin

Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) 5 EHR Process Y 62.16 - 66.66 66.67 - 71.42 71.43 - 74.90 74.91 - 77.60 77.61 - 82.60 82.61 - 85.70 85.71 - 90.90 >= 90.91 No

Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin

Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) 5 Registry/QCDR Process Y 75.86 - 79.48 79.49 - 82.13 82.14 - 84.99 85.00 - 87.49 87.50 - 89.99 90.00 - 93.53 93.54 - 96.54 >= 96.55 No

Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and

Older 50 Claims Process Y 92.86 - 97.02 97.03 - 99.99 -- -- -- -- -- 100 Yes

Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and

Older 50 Registry/QCDR Process Y 73.48 - 86.08 86.09 - 94.33 94.34 - 97.66 97.67 - 99.99 -- -- -- 100 Yes

Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation 51 Claims Process Y 21.61 - 59.99 60.00 - 85.49 85.50 - 96.61 96.62 - 99.99 -- -- -- 100 Yes

Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation 51 Registry/QCDR Process Y 50.53 - 58.59 58.60 - 69.43 69.44 - 77.97 77.98 - 86.43 86.44 - 93.17 93.18 - 97.65 97.66 - 99.99 100 No

Chronic Obstructive Pulmonary Disease (COPD): Inhaled Bronchodilator Therapy 52 Claims Process Y -- -- -- -- -- -- -- 100 Yes

Chronic Obstructive Pulmonary Disease (COPD): Inhaled Bronchodilator Therapy 52 Registry/QCDR Process Y 95.24 - 99.99 -- -- -- -- -- -- 100 Yes

Asthma: Pharmacologic Therapy for Persistent Asthma - Ambulatory Care Setting 53 Registry/QCDR Process Y 90.16 - 92.85 92.86 - 95.30 95.31 - 96.29 96.30 - 97.43 97.44 - 99.99 -- -- 100 Yes

Emergency Medicine: 12-Lead Electrocardiogram (ECG) Performed for Non-Traumatic

Chest Pain 54 Claims Process Y 95.45 - 96.87 96.88 - 98.03 98.04 - 99.99 -- -- -- -- 100 Yes

Emergency Medicine: 12-Lead Electrocardiogram (ECG) Performed for Non-Traumatic

Chest Pain 54 Registry/QCDR Process Y 95.45 - 98.26 98.27 - 99.55 99.56 - 99.99 -- -- -- -- 100 Yes

Coronary Artery Disease (CAD): Antiplatelet Therapy 6 Registry/QCDR Process Y 76.92 - 81.75 81.76 - 84.99 85.00 - 87.53 87.54 - 90.22 90.23 - 92.54 92.55 - 95.64 95.65 - 99.99 100 No

Appropriate Treatment for Children with Upper Respiratory Infection (URI) 65 EHR Process Y 70.45 - 79.99 80.00 - 87.99 88.00 - 93.05 93.06 - 95.64 95.65 - 97.29 97.30 - 98.96 98.97 - 99.99 100 No

Appropriate Treatment for Children with Upper Respiratory Infection (URI) 65 Registry/QCDR Process Y 67.74 - 80.76 80.77 - 91.07 91.08 - 94.74 94.75 - 99.99 -- -- -- 100 No

Appropriate Testing for Children with Pharyngitis 66 EHR Process Y 38.12 - 52.32 52.33 - 67.64 67.65 - 74.56 74.57 - 80.94 80.95 - 85.70 85.71 - 89.15 89.16 - 94.20 >= 94.21 No


Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline

Cytogenetic Testing Performed on Bone Marrow 67 Registry/QCDR Process Y 95.00 - 96.87 96.88 - 98.69 98.70 - 99.99 -- -- -- -- 100 Yes

Coronary Artery Disease (CAD): Beta-Blocker Therapy - Prior Myocardial Infarction (MI) or

Left Ventricular Systolic Dysfunction (LVEF < 40%) 7 EHR Process Y 61.21 - 71.99 72.00 - 76.62 76.63 - 80.76 80.77 - 84.00 84.01 - 88.88 88.89 - 92.65 92.66 - 98.14 >= 98.15 No

Coronary Artery Disease (CAD): Beta-Blocker Therapy - Prior Myocardial Infarction (MI) or

Left Ventricular Systolic Dysfunction (LVEF < 40%) 7 Registry/QCDR Process Y 74.51 - 78.56 78.57 - 81.51 81.52 - 84.53 84.54 - 86.97 86.98 - 89.35 89.36 - 92.58 92.59 - 97.91 >= 97.92 No

Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry 70 Registry/QCDR Process Y 86.52 - 95.23 95.24 - 99.50 99.51 - 99.99 -- -- -- -- 100 Yes

Breast Cancer: Hormonal Therapy for Stage IC - IIIC Estrogen Receptor/Progesterone

Receptor (ER/PR) Positive Breast Cancer 71 Claims Process Y -- -- -- -- -- -- -- 100 Yes


Receptor (ER/PR) Positive Breast Cancer 71 Registry/QCDR Process Y 80.49 - 90.78 90.79 - 96.48 96.49 - 98.07 98.08 - 99.99 -- -- -- 100 Yes

Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections 76 Claims Process Y 85.71 - 94.28 94.29 - 97.17 97.18 - 99.42 99.43 - 99.99 -- -- -- 100 Yes

Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections 76 Registry/QCDR Process Y 89.66 - 95.99 96.00 - 99.99 -- -- -- -- -- 100 Yes

Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) 8 EHR Process Y 58.62 - 64.70 64.71 - 71.94 71.95 - 78.25 78.26 - 85.50 85.51 - 89.99 90.00 - 91.66 91.67 - 95.99 >= 96.00 No

Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) 8 Registry/QCDR Process Y 75.68 - 81.07 81.08 - 85.57 85.58 - 88.43 88.44 - 91.16 91.17 - 94.28 94.29 - 96.36 96.37 - 99.99 100 No

Anti-depressant Medication Management 9 EHR Process Y 0.97 - 1.27 1.28 - 1.52 1.53 - 1.84 1.85 - 2.37 2.38 - 3.99 4.00 - 61.47 61.48 - 80.62 >= 80.63 No

Acute Otitis Externa (AOE): Topical Therapy 91 Claims Process Y 60.87 - 85.70 85.71 - 96.96 96.97 - 99.99 -- -- -- -- 100 Yes

Acute Otitis Externa (AOE): Topical Therapy 91 Registry/QCDR Process Y 60.47 - 69.56 69.57 - 78.25 78.26 - 83.01 83.02 - 87.97 87.98 - 93.32 93.33 - 99.99 -- 100 No

Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy - Avoidance of Inappropriate

Use 93 Claims Process Y 94.29 - 95.64 95.65 - 97.29 97.30 - 99.99 -- -- -- -- 100 Yes

Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy - Avoidance of Inappropriate

Use 93 Registry/QCDR Process Y 73.91 - 84.74 84.75 - 90.90 90.91 - 95.82 95.83 - 99.99 -- -- -- 100 Yes

Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN

Category (Regional Lymph Nodes) with Histologic Grade 99 Claims Process Y -- -- -- -- -- -- -- 100 Yes

Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN

Category (Regional Lymph Nodes) with Histologic Grade 99 Registry/QCDR Process Y 97.62 - 99.99 -- -- -- -- -- -- 100 Yes

Anesthesia Safety in the Peri-Operative Period ABG 1 Registry/QCDR Outcome Y 99.44 - 99.54 99.55 - 99.83 99.84 - 99.99 -- -- -- -- 100 Yes

Day of Surgery Case Cancellation Rate ABG 10 Registry/QCDR Process Y 7.71 - 4.20 4.19 - 0.23 0.22 - 0.01 -- -- -- -- 0 Yes

Anaphylaxis During Anesthesia Care ABG 11 Registry/QCDR Outcome Y -- -- -- -- -- -- -- 0 Yes

Total Perioperative Cardiac Arrest Rate ABG 2 Registry/QCDR Outcome Y -- -- -- -- -- -- -- 0 Yes

Total Perioperative Mortality Rate ABG 3 Registry/QCDR Outcome Y -- -- -- -- -- -- -- 0 Yes

OR Fire ABG 9 Registry/QCDR Outcome Y -- -- -- -- -- -- -- 0 Yes

Hypertension (HTN): Blood Pressure (BP) Management ACCPin 1 Registry/QCDR Process Y 80.04 - 84.15 84.16 - 86.65 86.66 - 88.55 88.56 - 89.84 89.85 - 91.05 91.06 - 92.34 92.35 - 93.89 >= 93.90 No

Coronary Artery Disease (CAD): Blood Pressure Control ACCPin 2 Registry/QCDR Outcome Y 81.51 - 85.87 85.88 - 88.51 88.52 - 90.49 90.50 - 91.71 91.72 - 92.90 92.91 - 94.15 94.16 - 95.53 >= 95.54 No

Pregnancy Test for Female Abdominal Pain Patients ACEP 11 Registry/QCDR Process Y 44.35 - 52.67 52.68 - 59.32 59.33 - 67.29 67.30 - 72.62 72.63 - 84.72 84.73 - 87.13 87.14 - 89.23 >= 89.24 No

Three day return rate ED ACEP 12 Registry/QCDR Outcome Y 15.53 - 14.41 14.40 - 13.46 13.45 - 12.01 12.00 - 11.11 11.10 - 10.52 10.51 - 10.11 10.10 - 9.22 <= 9.21 No

Adult Sinusitis: Appropriate Choice of Antibiotic ACEP 17 Registry/QCDR Process Y 47.19 - 51.88 51.89 - 57.13 57.14 - 60.33 60.34 - 62.36 62.37 - 65.25 65.26 - 67.30 67.31 - 73.63 >= 73.64 No

Coagulation Studies in Patients Presenting with Chest Pain with No Coagulopathy or

Bleeding ACEP 3 Registry/QCDR Process Y 92.79 - 89.91 89.90 - 87.35 87.34 - 61.63 61.62 - 52.01 52.00 - 42.23 42.22 - 31.98 31.97 - 27.10 <= 27.09 No

Disease Activity Measurement for Patients with Rheumatoid Arthritis (RA) ACR 1 Registry/QCDR Process Y 45.52 - 70.28 70.29 - 76.05 76.06 - 86.10 86.11 - 92.41 92.42 - 99.25 99.26 - 99.99 -- 100 No

Functional Status Assessment for Patients with Rheumatoid Arthritis (RA) ACR 2 Registry/QCDR Process Y 42.02 - 62.49 62.50 - 71.04 71.05 - 80.78 80.79 - 86.22 86.23 - 91.68 91.69 - 98.00 98.01 - 99.99 100 No

Disease-Modifying Anti-Rheumatic Drug (DMARD) Therapy for Active Rheumatoid

Arthritis (RA) ACR 3 Registry/QCDR Process Y 86.10 - 88.31 88.32 - 90.60 90.61 - 92.79 92.80 - 94.04 94.05 - 94.91 94.92 - 96.29 96.30 - 97.48 >= 97.49 No

Tuberculosis Test Prior to First Course Biologic Therapy ACR 4 Registry/QCDR Process Y 23.08 - 37.92 37.93 - 47.16 47.17 - 55.04 55.05 - 64.28 64.29 - 72.33 72.34 - 84.61 84.62 - 94.96 >= 94.97 No

Glucocorticosteroids and Other Secondary Causes ACR 5 Registry/QCDR Process Y 52.44 - 55.80 55.81 - 63.74 63.75 - 71.67 71.68 - 77.60 77.61 - 84.90 84.91 - 88.88 88.89 - 94.19 >= 94.20 No

Serum Urate Monitoring ACR 6 Registry/QCDR Process Y 26.67 - 36.35 36.36 - 41.66 41.67 - 44.29 44.30 - 54.16 54.17 - 60.86 60.87 - 65.21 65.22 - 73.90 >= 73.91 No

Participation in a National Dose Index Registry ACRad 14 Registry/QCDR Process Y -- 99.68 - 99.91 99.92 - 99.95 99.96 - 99.97 99.98 - 99.99 -- -- 100 Yes

CT IV Contrast Extravasation Rate (Low Osmolar Contrast Media) ACRad 20 Registry/QCDR Outcome Y 0.13 - 0.13 -- -- 0.12 - 0.01 -- -- -- 0 Yes

Screening Mammography Cancer Detection Rate (CDR) ACRad 3 Registry/QCDR Outcome Y 3.54 - 4.32 4.33 - 4.80 4.81 - 5.15 5.16 - 5.47 5.48 - 5.71 5.72 - 6.68 6.69 - 8.10 >= 8.11 No

Screening Mammography Invasive Cancer Detection Rate (ICDR) ACRad 4 Registry/QCDR Outcome Y 2.59 - 2.82 2.83 - 3.51 3.52 - 4.27 4.28 - 4.63 4.64 - 5.17 5.18 - 5.56 5.57 - 6.17 >= 6.18 No

Screening Mammography Abnormal Interpretation Rate (Recall Rate) ACRad 5 Registry/QCDR Outcome Y 13.98 - 11.03 11.02 - 9.94 9.93 - 9.24 9.23 - 8.21 8.20 - 7.22 7.21 - 6.39 6.38 - 5.27 <= 5.26 No

Screening Mammography Positive Predictive Value 2 (PPV2 - BiopsyRecommended) ACRad 6 Registry/QCDR Outcome Y 13.53 - 17.90 17.91 - 20.33 20.34 - 21.54 21.55 - 24.99 25.00 - 28.25 28.26 - 39.46 39.47 - 42.58 >= 42.59 No

Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care

from Procedure Room to Intensive Care Unit (ICU) AQI 1 Registry/QCDR Process Y 98.39 - 99.72 99.73 - 99.99 -- -- -- -- -- 100 Yes

Composite Procedural Safety for Central Line Placement AQI 10 Registry/QCDR Outcome Y 99.69 - 99.82 99.83 - 99.99 -- -- -- -- -- 100 Yes

Composite Patient Experience Measure AQI 11 Registry/QCDR Process Y 0.25 - 1.29 1.30 - 93.42 93.43 - 98.69 98.70 - 99.47 99.48 - 99.99 -- -- 100 Yes

Perioperative Care: Timely Administration of Prophylactic Parenteral Antibiotics AQI 12 Registry/QCDR Process Y 97.75 - 99.23 99.24 - 99.67 99.68 - 99.99 -- -- -- -- 100 Yes

Perioperative Temperature Managament AQI 13 Registry/QCDR Outcome Y 73.28 - 90.78 90.79 - 95.50 95.51 - 99.16 99.17 - 99.77 99.78 - 99.99 -- -- 100 No

Preoperative Use of Aspirin for Patients with Drug-Eluting Coronary Stents AQI 14 Registry/QCDR Process Y 97.10 - 98.47 98.48 - 99.13 99.14 - 99.54 99.55 - 99.78 99.79 - 99.99 -- -- 100 Yes

Surgical Safety Checklist - Applicable Safety Checks Completed Before Induction of

Anesthesia AQI 15 Registry/QCDR Process Y 99.27 - 99.99 -- -- -- -- -- -- 100 Yes

Smoking Abstinence Measure AQI 16 Registry/QCDR Outcome Y 76.56 - 88.93 88.94 - 97.51 97.52 - 98.83 98.84 - 99.38 99.39 - 99.87 99.88 - 99.99 -- 100 No


Corneal Injury Diagnosed in the Post-Anesthesia Care Unit/Recovery Area after

Anesthesia Care AQI 17 Registry/QCDR Process Y 99.56 - 99.99 -- -- -- -- -- -- 100 Yes

Coronary Artery Bypass Graft (CABG): Prolonged Intubation AQI 18 Registry/QCDR Outcome Y 91.06 - 94.96 94.97 - 98.83 98.84 - 99.63 99.64 - 99.99 -- -- -- 100 Yes

Prevention of Post-Operative Nausea and Vomiting (PONV) - Combination Therapy

(Adults) AQI 2 Registry/QCDR Process Y 86.43 - 95.07 95.08 - 97.93 97.94 - 98.94 98.95 - 99.57 99.58 - 99.99 -- -- 100 Yes

Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure AQI 20 Registry/QCDR Outcome Y 99.06 - 99.84 99.85 - 99.99 -- -- -- -- -- 100 Yes

Rate of Postoperative Stroke or Death in Asymptomatic Patients Undergoing Carotid

Artery Stenting (CAS) AQI 21 Registry/QCDR Outcome Y 38.75 - 44.99 45.00 - 51.84 51.85 - 57.13 57.14 - 64.70 64.71 - 77.49 77.50 - 83.86 83.87 - 95.82 >= 95.83 No

Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet AQI 25 Registry/QCDR Outcome Y 94.87 - 97.99 98.00 - 99.99 -- -- -- -- -- 100 Yes

Prevention of Post-Operative Vomiting (POV) - Combination Therapy (Pediatrics) AQI 3 Registry/QCDR Process Y 80.77 - 95.64 95.65 - 98.99 99.00 - 99.99 -- -- -- -- 100 Yes

Anesthesiology: Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post

Anesthesia Care Unit AQI 4 Registry/QCDR Process Y 97.00 - 99.46 99.47 - 99.99 -- -- -- -- -- 100 Yes

Composite Anesthesia Safety AQI 5 Registry/QCDR Outcome Y 99.40 - 99.58 99.59 - 99.72 99.73 - 99.81 99.82 - 99.90 99.91 - 99.99 -- -- 100 Yes

Immediate Perioperative Cardiac Arrest Rate AQI 6 Registry/QCDR Outcome Y 0.11 - 0.13 0.14 - 0.18 0.19 - 0.24 0.25 - 0.31 0.32 - 0.50 0.51 - 0.81 0.82 - 1.49 >= 1.50 No

Immediate Perioperative Mortality Rate AQI 7 Registry/QCDR Outcome Y 0.10 - 0.13 0.14 - 0.16 0.17 - 0.19 0.20 - 0.23 0.24 - 0.28 0.29 - 0.34 0.35 - 0.60 >= 0.61 No

PACU Reintubation Rate AQI 8 Registry/QCDR Outcome Y 0.19 - 0.23 0.24 - 0.28 0.29 - 0.36 0.37 - 0.50 0.51 - 0.69 0.70 - 1.18 1.19 - 2.27 >= 2.28 No

Short-term Pain Management AQI 9 Registry/QCDR Outcome Y 96.69 - 98.46 98.47 - 99.19 99.20 - 99.58 99.59 - 99.83 99.84 - 99.99 -- -- 100 Yes

Surgeon assessment for hereditary cause of breast cancer ASBS 1 Registry/QCDR Process Y 98.70 - 99.41 99.42 - 99.99 -- -- -- -- -- 100 Yes

Surgical Site Infection and Cellulitis After Breast and/or Axillary Surgery ASBS 2 Registry/QCDR Outcome Y 2.90 - 2.40 2.39 - 1.70 1.69 - 1.09 1.08 - 0.52 0.51 - 0.01 -- -- 0 Yes

Specimen orientation for partial mastectomy or excisional breast biopsy ASBS 3 Registry/QCDR Process Y 99.36 - 99.99 -- -- -- -- -- -- 100 Yes


Cephalosporin ASBS 5 Registry/QCDR Process Y -- -- -- -- -- -- -- 100 Yes


Procedures) ASBS 6 Registry/QCDR Process Y -- -- -- -- -- -- -- 100 Yes

Unplanned 30 day re-operation after mastectomy ASBS 7 Registry/QCDR Outcome Y 95.45 - 97.05 97.06 - 98.83 98.84 - 99.99 -- -- -- -- 100 Yes

Colloid use limited in cases with no indication ASPIRE 11 Registry/QCDR Process Y 97.24 - 97.56 97.57 - 97.75 97.76 - 98.11 98.12 - 98.45 98.46 - 98.73 98.74 - 99.02 99.03 - 99.56 >= 99.57 Yes

Avoiding intraoperative hypotension ASPIRE 16 Registry/QCDR Process Y 91.67 - 92.72 92.73 - 94.61 94.62 - 99.54 99.55 - 99.72 99.73 - 99.85 99.86 - 99.88 99.89 - 99.99 100 Yes

Avoiding gaps in systolic or mean arterial pressure measurement ASPIRE 17 Registry/QCDR Process Y 77.59 - 80.74 80.75 - 90.44 90.45 - 91.11 91.12 - 92.21 92.22 - 92.89 92.90 - 93.71 93.72 - 94.86 >= 94.87 No

Avoiding myocardial Injury ASPIRE 18 Registry/QCDR Outcome Y 99.67 - 99.48 99.47 - 99.43 99.42 - 99.38 99.37 - 99.28 99.27 - 99.02 99.01 - 98.83 98.82 - 98.49 <= 98.48 No

Train of Four Monitor Documented After Last Dose of Non-depolarizing Neuromuscular

Blocker ASPIRE 2 Registry/QCDR Process Y 78.96 - 80.94 80.95 - 82.72 82.73 - 83.47 83.48 - 84.42 84.43 - 86.07 86.08 - 88.08 88.09 - 90.33 >= 90.34 No

Avoiding medication overdose ASPIRE 22 Registry/QCDR Outcome Y 99.76 - 99.70 99.69 - 99.65 99.64 - 99.51 99.50 - 99.39 99.38 - 99.32 99.31 - 99.30 99.29 - 98.92 <= 98.91 No

Administration of Neostigmine before Extubation for Cases with Nondepolarizing

Neuromuscular Blockade ASPIRE 3 Registry/QCDR Process Y 89.03 - 90.25 90.26 - 93.55 93.56 - 96.79 96.80 - 97.96 97.97 - 98.41 98.42 - 98.89 98.90 - 99.30 >= 99.31 Yes

Avoiding excessively high tidal volumes during positive pressure ventilation ASPIRE 6 Registry/QCDR Process Y 89.66 - 91.38 91.39 - 92.67 92.68 - 94.06 94.07 - 95.28 95.29 - 95.46 95.47 - 95.97 95.98 - 96.54 >= 96.55 No

Adequate Off-loading of Diabetic Foot Ulcers at each visit CDR 1 Registry/QCDR Process Y 40.13 - 58.05 58.06 - 72.34 72.35 - 83.92 83.93 - 91.29 91.30 - 95.29 95.30 - 97.41 97.42 - 98.87 >= 98.88 No

Vascular Assessment of patients with chronic leg ulcers CDR 10 Registry/QCDR Process Y 28.14 - 36.46 36.47 - 43.95 43.96 - 57.95 57.96 - 68.13 68.14 - 73.73 73.74 - 77.31 77.32 - 79.51 >= 79.52 No

Wound Bed Preparation Through Debridement of Necrotic or Non-viable Tissue CDR 11 Registry/QCDR Process Y 56.64 - 65.37 65.38 - 78.33 78.34 - 86.19 86.20 - 94.63 94.64 - 97.10 97.11 - 98.37 98.38 - 99.34 >= 99.35 No

Diabetic Foot & Ankle Care: Comprehensive Diabetic Foot Examination CDR 4 Registry/QCDR Process Y 13.04 - 16.21 16.22 - 22.02 22.03 - 25.62 25.63 - 31.02 31.03 - 33.32 33.33 - 35.99 36.00 - 41.66 >= 41.67 No

Adequate Compression at each visit for Patients with Venous Leg Ulcers (VLU) CDR 5 Registry/QCDR Process Y 75.20 - 90.31 90.32 - 93.58 93.59 - 94.63 94.64 - 95.82 95.83 - 97.23 97.24 - 99.09 99.10 - 99.99 100 No

Three Day All Cause Return ED Visit Rate - All Patients ECPR 11 Registry/QCDR Outcome Y 6.46 - 6.05 6.04 - 5.72 5.71 - 5.40 5.39 - 5.08 5.07 - 4.76 4.75 - 4.35 4.34 - 3.94 <= 3.93 No

Three Day All Cause Return ED Visit Rate - Adults ECPR 12 Registry/QCDR Outcome Y 6.96 - 6.54 6.53 - 6.15 6.14 - 5.79 5.78 - 5.45 5.44 - 5.13 5.12 - 4.75 4.74 - 4.30 <= 4.29 No

Three Day All Cause Return ED Visit Rate - Pediatrics ECPR 13 Registry/QCDR Outcome Y 4.29 - 3.90 3.89 - 3.54 3.53 - 3.19 3.18 - 2.77 2.76 - 2.34 2.33 - 1.94 1.93 - 1.36 <= 1.35 No

Three Day All Cause Return ED Visit Rate with Placement Into Inpatient or Observation

Status on Re-Visit ECPR 17 Registry/QCDR Outcome Y 1.46 - 1.29 1.28 - 1.16 1.15 - 1.06 1.05 - 0.96 0.95 - 0.84 0.83 - 0.71 0.70 - 0.55 <= 0.54 No

Avoid Head CT in Patients with Uncomplicated Syncope ECPR 18 Registry/QCDR Process Y 74.00 - 78.78 78.79 - 82.60 82.61 - 86.04 86.05 - 88.36 88.37 - 90.90 90.91 - 93.32 93.33 - 96.29 >= 96.30 No

Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged

18 Years and Older ECPR 19 Registry/QCDR Process Y 46.15 - 57.13 57.14 - 65.37 65.38 - 70.89 70.90 - 79.99 80.00 - 85.70 85.71 - 89.99 90.00 - 95.23 >= 95.24 No

Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2

to 17 Years ECPR 20 Registry/QCDR Process Y 78.26 - 86.83 86.84 - 93.32 93.33 - 94.28 94.29 - 94.99 95.00 - 96.87 96.88 - 99.99 -- 100 No

Avoid Imaging with X-Rays in Non-traumatic Low Back Pain ECPR 21 Registry/QCDR Process Y 85.00 - 89.99 90.00 - 91.99 92.00 - 94.51 94.52 - 95.64 95.65 - 97.13 97.14 - 99.99 -- 100 No

Appropriate Treatment for Children with Upper Respiratory Infection (URI) - Were Not

Dispensed an Antibiotic Prescription ECPR 23 Registry/QCDR Process Y 95.00 - 95.99 96.00 - 96.87 96.88 - 99.34 99.35 - 99.99 -- -- -- 100 Yes

Initiation of the Initial Sepsis Bundle ECPR 24 Registry/QCDR Process Y 78.57 - 84.61 84.62 - 88.88 88.89 - 91.73 91.74 - 94.99 95.00 - 96.29 96.30 - 97.72 97.73 - 99.99 100 No

Pain Management for Long Bone Fracture ECPR 25 Registry/QCDR Outcome Y 90.32 - 92.30 92.31 - 94.82 94.83 - 95.64 95.65 - 96.42 96.43 - 97.86 97.87 - 99.99 -- 100 Yes

Pregnancy Test for Female Abdominal Pain Patients ECPR 26 Registry/QCDR Process Y 78.57 - 81.81 81.82 - 84.61 84.62 - 86.83 86.84 - 88.93 88.94 - 90.62 90.63 - 92.69 92.70 - 95.11 >= 95.12 No

Rh Status Evaluation of Pregnant Women at Risk of Fetal Blood Exposure ECPR 27 Registry/QCDR Process Y 67.05 - 72.78 72.79 - 76.25 76.26 - 79.30 79.31 - 81.81 81.82 - 85.95 85.96 - 90.39 90.40 - 94.14 >= 94.15 No

Coagulation Studies in Patients Presenting with Chest Pain with No Coagulopathy or

Bleeding ECPR 28 Registry/QCDR Process Y 57.93 - 68.03 68.04 - 77.54 77.55 - 83.03 83.04 - 86.89 86.90 - 89.99 90.00 - 93.03 93.04 - 95.61 >= 95.62 No

Adenoma detection rate GIQIC 1 Registry/QCDR Outcome Y 28.99 - 32.18 32.19 - 35.75 35.76 - 38.80 38.81 - 41.92 41.93 - 45.74 45.75 - 49.29 49.30 - 54.69 >= 54.70 No

Appropriate management of anticoagulation in the peri-procedural period rate - EGD GIQIC 10 Registry/QCDR Process Y 68.37 - 89.99 90.00 - 97.91 97.92 - 99.99 -- -- -- -- 100 Yes

Appropriate indication for colonoscopy GIQIC 12 Registry/QCDR Process Y 82.27 - 86.05 86.06 - 89.06 89.07 - 91.34 91.35 - 93.27 93.28 - 94.80 94.81 - 96.59 96.60 - 98.44 >= 98.45 No


Repeat screening colonoscopy recommended within one year due to inadequate bowel

preparation GIQIC 14 Registry/QCDR Outcome Y 17.47 - 21.14 21.15 - 26.76 26.77 - 39.57 39.58 - 53.00 53.01 - 69.22 69.23 - 75.42 75.43 - 82.75 >= 82.76 No

Appropriate follow-up interval of 3 years recommended based on pathology findings from

screening colonoscopy in average-risk patients GIQIC 15 Registry/QCDR Process Y 68.18 - 74.32 74.33 - 77.87 77.88 - 80.70 80.71 - 85.23 85.24 - 89.17 89.18 - 91.34 91.35 - 94.38 >= 94.39 No

Adequacy of bowel preparation GIQIC 2 Registry/QCDR Process Y 91.43 - 93.72 93.73 - 95.56 95.57 - 96.64 96.65 - 97.46 97.47 - 98.11 98.12 - 98.67 98.68 - 99.27 >= 99.28 Yes

Photodocumentation of the cecum (also known as cecal intubation rate) - All

Colonoscopies GIQIC 3 Registry/QCDR Process Y 95.36 - 96.82 96.83 - 97.49 97.50 - 98.02 98.03 - 98.50 98.51 - 98.85 98.86 - 99.22 99.23 - 99.57 >= 99.58 Yes

Photodocumentation of the cecum (also known as cecal intubation rate) - Screening

Colonoscopies GIQIC 4 Registry/QCDR Process Y 96.46 - 97.61 97.62 - 98.30 98.31 - 98.76 98.77 - 99.10 99.11 - 99.43 99.44 - 99.68 99.69 - 99.99 100 Yes

Incidence of perforation GIQIC 5 Registry/QCDR Outcome Y -- -- -- -- -- -- -- 0 Yes

Appropriate follow-up interval for normal colonoscopy in average risk patients GIQIC 6 Registry/QCDR Process Y 82.14 - 87.00 87.01 - 89.65 89.66 - 91.83 91.84 - 93.74 93.75 - 95.09 95.10 - 96.59 96.60 - 98.20 >= 98.21 No

Age appropriate screening colonoscopy GIQIC 8 Registry/QCDR Outcome Y -- -- -- -- -- -- -- 0 Yes

Documentation of history and physical rate - Colonoscopy GIQIC 9 Registry/QCDR Process Y 98.50 - 99.22 99.23 - 99.67 99.68 - 99.99 -- -- -- -- 100 Yes

Nonexudative Age-Related Macular Degeneration: Loss of Visual Acuity IRIS 11 Registry/QCDR Outcome Y 72.97 - 79.58 79.59 - 85.70 85.71 - 95.58 95.59 - 97.43 97.44 - 99.99 -- -- 100 No

Risk standardized rate of patients who experienced a postoperative complication within

30 days following a Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve

Gastrectomy operation, performed as a primary (not revisional) procedure. MBSAQIP 1 Registry/QCDR Outcome Y 7.87 - 6.92 6.91 - 5.74 5.73 - 4.64 4.63 - 3.86 3.85 - 2.95 2.94 - 1.00 0.99 - 0.01 0 No

Risk standardized rate of patients who experienced an unplanned readmission (likely

related to the initial operation) to any hospital within 30 days following a Laparoscopic

Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation, performed as a

primary (not revisional) procedure. MBSAQIP 2 Registry/QCDR Outcome Y 4.84 - 3.73 3.72 - 3.24 3.23 - 2.96 2.95 - 1.86 1.85 - 1.16 1.15 - 0.01 -- 0 Yes

Risk standardized rate of patients who experienced a reoperation (likely related to the

initial operation) within 30 days following a Laparoscopic Roux-en-Y Gastric Bypass or

Laparoscopic Sleeve Gastrectomy operation, performed as a primary (not revisional)

procedure. MBSAQIP 3 Registry/QCDR Outcome Y 2.38 - 1.73 1.72 - 0.62 0.61 - 0.01 -- -- -- -- 0 Yes

Risk standardized rate of patients who experienced an anastomotic/staple line leak within

30 days following a Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve

Gastrectomy operation, performed as a primary (not revisional) procedure. MBSAQIP 4 Registry/QCDR Outcome Y -- -- -- -- -- -- -- 0 Yes

Risk standardized rate of patients who experienced a bleeding/hemorrhage event

requiring transfusion, intervention/operation, or readmission within 30 days following a

Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation,

performed as a primary (not revisional) procedure. MBSAQIP 5 Registry/QCDR Outcome Y 1.72 - 0.80 0.79 - 0.54 0.53 - 0.01 -- -- -- -- 0 Yes

Risk standardized rate of patients who experienced a postoperative surgical site infection

(SSI) (superficial incisional, deep incisional, or organ/space SSI) within 30 days following a

Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation,

performed as a primary (not revisional) procedure. MBSAQIP 6 Registry/QCDR Outcome Y 1.61 - 0.64 0.63 - 0.01 -- -- -- -- -- 0 Yes

Risk standardized rate of patients who experienced postoperative nausea, vomiting or

fluid/electrolyte/nutritional depletion within 30 days following a Laparoscopic Roux-en-Y

Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation, performed as a primary

(not revisional) procedure. MBSAQIP 7 Registry/QCDR Outcome Y 2.56 - 2.27 2.26 - 1.53 1.52 - 0.79 0.78 - 0.01 -- -- -- 0 Yes

Risk standardized rate of patients who experienced extended length of stay (> 7 days)

following a Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy

operation, performed as a primary (not revisional) procedure. MBSAQIP 8 Registry/QCDR Outcome Y 1.37 - 0.54 0.53 - 0.01 -- -- -- -- -- 0 Yes

Percentage of patients who had complete 30 day follow-up following any metabolic and

bariatric procedure. MBSAQIP 9 Registry/QCDR Process Y 96.31 - 97.58 97.59 - 98.10 98.11 - 98.62 98.63 - 99.48 99.49 - 99.99 -- -- 100 Yes

Prostate Biopsy: Compliance with AUA best practices for antibiotic prophylaxis for

transrectal ultrasound-guided (TRUS) biopsy MUSIC 1 Registry/QCDR Process Y 94.12 - 97.82 97.83 - 98.10 98.11 - 99.28 99.29 - 99.99 -- -- -- 100 Yes

Unplanned Hospital Admission within 30 Days of TRUS Biopsy: MUSIC 2 Registry/QCDR Outcome Y 1.28 - 0.01 -- -- -- -- -- -- 0 Yes

Prostate Biopsy: Proportion of patients undergoing initial prostate biopsy in the registry

found to have prostate cancer MUSIC 7 Registry/QCDR Outcome Y 50.00 - 51.94 51.95 - 53.02 53.03 - 55.71 55.72 - 57.13 57.14 - 58.61 58.62 - 59.51 59.52 - 61.75 >= 61.76 No

Prostate Biopsy: Proportion of patients undergoing a prostate biopsy with a PSA < 4 MUSIC 8 Registry/QCDR Process Y 23.08 - 18.47 18.46 - 16.01 16.00 - 14.86 14.85 - 13.65 13.64 - 11.12 11.11 - 10.35 10.34 - 8.87 <= 8.86 No

Orthopedic Pain: Mental Health Assessment OBERD 6 Registry/QCDR Process Y 5.73 - 7.61 7.62 - 10.91 10.92 - 14.51 14.52 - 17.75 17.76 - 21.62 21.63 - 26.97 26.98 - 37.62 >= 37.63 No

Orthopedic Pain: Assessment and follow--?up OBERD 9 Registry/QCDR Process Y 37.51 - 42.78 42.79 - 50.58 50.59 - 53.93 53.94 - 58.28 58.29 - 63.36 63.37 - 66.86 66.87 - 70.96 >= 70.97 No

Venous Thromboembolism (VTE) Prophylaxis PInc 7 Registry/QCDR Outcome Y -- -- -- -- -- -- -- 100 Yes

Diabetes Mellitus (DM): Hemoglobin A1c Control (< 8%) PPRNET 1 Registry/QCDR Outcome Y 62.69 - 64.28 64.29 - 65.90 65.91 - 68.23 68.24 - 69.99 70.00 - 70.49 70.50 - 71.66 71.67 - 74.99 >= 75.00 No

Screening for Abdominal Aortic Aneurysm PPRNET 12 Registry/QCDR Process Y 2.78 - 4.19 4.20 - 6.66 6.67 - 7.83 7.84 - 8.69 8.70 - 15.93 15.94 - 24.99 25.00 - 46.42 >= 46.43 No

Chronic Kidney Disease (CKD): eGFR Monitoring PPRNET 13 Registry/QCDR Process Y 59.02 - 63.42 63.43 - 66.66 66.67 - 72.34 72.35 - 74.59 74.60 - 78.25 78.26 - 85.05 85.06 - 86.95 >= 86.96 No

Chronic Kidney Disease (CKD): Hemoglobin Monitoring PPRNET 14 Registry/QCDR Process Y 66.67 - 77.26 77.27 - 83.86 83.87 - 87.49 87.50 - 88.63 88.64 - 90.47 90.48 - 91.66 91.67 - 93.74 >= 93.75 No

Osteoporosis Screening for Women PPRNET 15 Registry/QCDR Process Y 16.80 - 23.69 23.70 - 44.43 44.44 - 53.24 53.25 - 57.62 57.63 - 65.28 65.29 - 68.32 68.33 - 78.64 >= 78.65 No

Cervical Cancer Screening PPRNET 16 Registry/QCDR Process Y 20.70 - 27.94 27.95 - 33.74 33.75 - 36.69 36.70 - 40.79 40.80 - 48.04 48.05 - 55.20 55.21 - 68.63 >= 68.64 No

Breast Cancer Screening PPRNET 17 Registry/QCDR Process Y 20.80 - 29.40 29.41 - 39.74 39.75 - 50.76 50.77 - 57.78 57.79 - 65.44 65.45 - 72.74 72.75 - 82.98 >= 82.99 No

Colorectal Cancer screening PPRNET 18 Registry/QCDR Process Y 40.00 - 44.33 44.34 - 54.80 54.81 - 59.34 59.35 - 61.18 61.19 - 71.11 71.12 - 73.54 73.55 - 76.26 >= 76.27 No


Pneumococcal Vaccination in Elderly PPRNET 19 Registry/QCDR Process Y 54.22 - 65.37 65.38 - 69.78 69.79 - 79.52 79.53 - 82.50 82.51 - 84.20 84.21 - 86.05 86.06 - 89.88 >= 89.89 No

Diabetes Mellitus (DM): Nephropathy Assessment PPRNET 2 Registry/QCDR Process Y 74.07 - 80.64 80.65 - 84.29 84.30 - 85.22 85.23 - 87.20 87.21 - 88.45 88.46 - 90.51 90.52 - 91.66 >= 91.67 No

Zoster (Shingles) Vaccination PPRNET 20 Registry/QCDR Process Y 11.15 - 32.73 32.74 - 41.89 41.90 - 53.56 53.57 - 56.51 56.52 - 58.25 58.26 - 66.42 66.43 - 68.85 >= 68.86 No

Depression Screening PPRNET 21 Registry/QCDR Process Y 14.03 - 19.70 19.71 - 32.75 32.76 - 41.56 41.57 - 46.42 46.43 - 64.00 64.01 - 78.68 78.69 - 83.73 >= 83.74 No

Alcohol Misuse Screening PPRNET 22 Registry/QCDR Process Y 7.20 - 11.49 11.50 - 34.51 34.52 - 39.05 39.06 - 46.85 46.86 - 58.15 58.16 - 77.21 77.22 - 91.44 >= 91.45 No

Tobacco Use: Screening and Cessation Intervention PPRNET 23 Registry/QCDR Process Y 83.22 - 86.67 86.68 - 92.28 92.29 - 92.58 92.59 - 92.79 92.80 - 94.29 94.30 - 96.92 96.93 - 98.34 >= 98.35 No

Use of High-Risk Medications in the Elderly PPRNET 26 Registry/QCDR Process Y 83.00 - 86.17 86.18 - 87.45 87.46 - 88.88 88.89 - 89.62 89.63 - 90.72 90.73 - 92.85 92.86 - 94.16 >= 94.17 No

NSAID or Cox 2 Inhibitor Use in Patients with Heart Failure (HF) or Chronic Kidney Disease

(CKD) PPRNET 28 Registry/QCDR Process Y 83.51 - 84.64 84.65 - 85.94 85.95 - 86.97 86.98 - 89.25 89.26 - 89.72 89.73 - 90.32 90.33 - 92.93 >= 92.94 No

Monitoring Serum Potassium PPRNET 29 Registry/QCDR Process Y 82.03 - 82.10 82.11 - 83.01 83.02 - 86.19 86.20 - 88.19 88.20 - 90.90 90.91 - 93.78 93.79 - 96.60 >= 96.61 No

Diabetes Mellitus (DM): Dilated Eye Exam PPRNET 3 Registry/QCDR Process Y 8.64 - 13.21 13.22 - 18.97 18.98 - 27.26 27.27 - 31.86 31.87 - 41.66 41.67 - 46.96 46.97 - 57.44 >= 57.45 No

Treatment of Hypokalemia PPRNET 30 Registry/QCDR Outcome Y 93.55 - 95.23 95.24 - 96.29 96.30 - 96.87 96.88 - 97.32 97.33 - 98.35 98.36 - 99.14 99.15 - 99.48 >= 99.49 Yes

Hypertension (HTN): Appropriate Diagnosis PPRNET 4 Registry/QCDR Process Y 80.36 - 80.98 80.99 - 84.54 84.55 - 88.13 88.14 - 89.50 89.51 - 90.19 90.20 - 92.58 92.59 - 93.17 >= 93.18 No

Hypertension (HTN): Controlling Blood Pressure PPRNET 5 Registry/QCDR Outcome Y 59.10 - 61.02 61.03 - 63.26 63.27 - 64.74 64.75 - 67.04 67.05 - 68.86 68.87 - 71.92 71.93 - 75.11 >= 75.12 No

Concordance with ACC/AHA Cholesterol Guidelines for ASCVD Risk Reduction PPRNET 6 Registry/QCDR Process Y 21.33 - 22.10 22.11 - 23.97 23.98 - 24.65 24.66 - 25.83 25.84 - 26.99 27.00 - 31.32 31.33 - 48.65 >= 48.66 No

Screening for Lipid Disorders in Adults PPRNET 7 Registry/QCDR Process Y 83.62 - 87.97 87.98 - 90.09 90.10 - 90.94 90.95 - 92.56 92.57 - 93.62 93.63 - 94.79 94.80 - 96.40 >= 96.41 No

Antiplatelet Medication for High Risk Patients PPRNET 8 Registry/QCDR Process Y 18.87 - 21.56 21.57 - 29.81 29.82 - 32.63 32.64 - 34.82 34.83 - 54.35 54.36 - 64.93 64.94 - 75.20 >= 75.21 No

Antithrombotic Medication for Patients with Atrial Fibrillation PPRNET 9 Registry/QCDR Process Y 55.95 - 59.81 59.82 - 68.74 68.75 - 73.32 73.33 - 74.99 75.00 - 82.97 82.98 - 85.70 85.71 - 87.49 >= 87.50 No

CABG- Prolonged postoperative length of stay (PLOS) STS 1 Registry/QCDR Outcome Y 8.42 - 6.59 6.58 - 5.34 5.33 - 4.04 4.03 - 3.34 3.33 - 2.48 2.47 - 1.44 1.43 - 0.01 0 No

CABG + Valve- Prolonged postoperative length of stay (PLOS) STS 3 Registry/QCDR Outcome Y 18.75 - 13.80 13.79 - 12.51 12.50 - 11.12 11.11 - 9.22 9.21 - 6.53 6.52 - 4.56 4.55 - 3.71 <= 3.70 No

Isolated Valve- Prolonged postoperative length of stay (PLOS) STS 5 Registry/QCDR Outcome Y 9.84 - 8.01 8.00 - 6.91 6.90 - 4.89 4.88 - 4.01 4.00 - 3.04 3.03 - 2.34 2.33 - 0.01 0 No

Perioperative Aspiration Pneumonia rate THPSO 1 Registry/QCDR Outcome Y -- -- -- -- -- -- -- 0 Yes

Postoperative nausea and vomiting rate - Pediatrics THPSO 10 Registry/QCDR Outcome Y -- -- -- -- -- -- -- 0 Yes

Post-obstructive Pulmonary Edema rate following endo-tracheal intubation THPSO 11 Registry/QCDR Outcome Y -- -- -- -- -- -- -- 0 Yes

Respiratory Arrest in PACU rate THPSO 12 Registry/QCDR Outcome Y -- -- -- -- -- -- -- 0 Yes

Dental Injury Rate following airway management THPSO 13 Registry/QCDR Outcome Y -- -- -- -- -- -- -- 0 Yes

Post-dural puncture headache rate THPSO 2 Registry/QCDR Outcome Y -- -- -- -- -- -- -- 0 Yes

Immediate Perioperative Cardiac Arrest Rate THPSO 20 Registry/QCDR Outcome Y -- -- -- -- -- -- -- 0 Yes

Immediate Perioperative Mortality Rate THPSO 21 Registry/QCDR Outcome Y -- -- -- -- -- -- -- 0 Yes

Perioperative Peripheral Nerve Injury rate THPSO 3 Registry/QCDR Outcome Y -- -- -- -- -- -- -- 0 Yes

Pneumothorax rate as a complication of central line placement THPSO 4 Registry/QCDR Outcome Y -- -- -- -- -- -- -- 0 Yes

Ultrasound guidance for central line placement THPSO 5 Registry/QCDR Process Y 7.83 - 9.08 9.09 - 15.28 15.29 - 23.15 23.16 - 33.32 33.33 - 48.27 48.28 - 56.75 56.76 - 83.94 >= 83.95 No

Perioperative Myocardial Infarction rate in low risk patients THPSO 6 Registry/QCDR Outcome Y -- -- -- -- -- -- -- 0 Yes

Perioperative Myocardial Infarction rate in high risk patients THPSO 7 Registry/QCDR Outcome Y -- -- -- -- -- -- -- 0 Yes

New perioperative central neurologic deficit THPSO 8 Registry/QCDR Outcome Y -- -- -- -- -- -- -- 0 Yes

Postoperative nausea and vomiting rate - Adults THPSO 9 Registry/QCDR Outcome Y -- -- -- -- -- -- -- 0 Yes

Patient Vital Sign Assessment Prior to HBOT USWR 13 Registry/QCDR Process Y 98.74 - 99.28 99.29 - 99.57 99.58 - 99.70 99.71 - 99.99 -- -- -- 100 Yes

Blood glucose check prior to hyperbaric oxygen therapy (HBOT) treatment USWR 14 Registry/QCDR Process Y 97.39 - 97.90 97.91 - 98.69 98.70 - 99.23 99.24 - 99.54 99.55 - 99.72 99.73 - 99.99 -- 100 Yes

Complications or Side Effects among patients undergoing Treatment with HBOT USWR 18 Registry/QCDR Outcome Y 98.99 - 99.07 99.08 - 99.48 99.49 - 99.78 99.79 - 99.84 99.85 - 99.99 -- -- 100 Yes

Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer

Patients 102 EHR Process N -- -- -- -- -- -- -- -- --

Oncology: Radiation Dose Limits to Normal Tissues 156 Claims Process N -- -- -- -- -- -- -- -- --

HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis 160 EHR Process N -- -- -- -- -- -- -- -- --

Hemodialysis Vascular Access Decision-Making by Surgeon to Maximize Placement of

Autogenous Arterial Venous (AV) Fistula 172 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis 205 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Knee

Impairments 217 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Hip

Impairments 218 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Lower Leg,

Foot or Ankle Impairments 219 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Lumbar

Spine Impairments 220 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Shoulder

Impairments 221 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Elbow,

Wrist or Hand Impairments 222 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Neck,

Cranium, Mandible, Thoracic Spine, Ribs, or Other General Orthopedic Impairments 223 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Weight Assessment and Counseling for Nutrition and Physical Activity for Children and

Adolescents 239 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Cardiac Rehabilitation Patient Referral from an Outpatient Setting 243 Registry/QCDR Process N -- -- -- -- -- -- -- -- --


Radical Prostatectomy Pathology Reporting 250 Registry/QCDR Structure N -- -- -- -- -- -- -- -- --

Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal

Pain 254 Claims Process N -- -- -- -- -- -- -- -- --

Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal

Pain 254 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood

Exposure 255 Claims Process N -- -- -- -- -- -- -- -- --

Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood

Exposure 255 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Statin Therapy at Discharge after Lower Extremity Bypass (LEB) 257 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Rate of Open Repair of Small or Moderate Non-Ruptured Abdominal Aortic Aneurysms

(AAA) without Major Complications (Discharged to Home by Post-Operative Day #7) 258 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured

Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by

Post-Operative Day #2) 259 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major

Complications (Discharged to Home by Post-Operative Day #2) 260 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness 261 Claims Process N -- -- -- -- -- -- -- -- --

Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness 261 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Image Confirmation of Successful Excision of Image-Localized Breast Lesion 262 Claims Process N -- -- -- -- -- -- -- -- --

Preoperative Diagnosis of Breast Cancer 263 Claims Process N -- -- -- -- -- -- -- -- --

Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy 268 Claims Outcome N -- -- -- -- -- -- -- -- --

Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy 268 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Sparing Therapy 270 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related Iatrogenic

Injury - Bone Loss Assessment 271 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Inflammatory Bowel Disease (IBD): Testing for Latent Tuberculosis (TB) Before Initiating

Anti-TNF (Tumor Necrosis Factor) Therapy 274 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before

Initiating Anti-TNF (Tumor Necrosis Factor) Therapy 275 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Dementia: Cognitive Assessment 281 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Use of Appropriate Medications for Asthma 311 Registry/QCDR Process N -- -- -- -- -- -- -- -- --


Performed 316A Registry/QCDR Process N -- -- -- -- -- -- -- -- --


Performed: AND Risk-Stratified Fasting LDL-C 316B Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Pediatric Kidney Disease: Adequacy of Volume Management 327 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Adult Kidney Disease: Catheter Use at Initiation of Hemodialysis 329 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Adult Kidney Disease: Catheter Use for Greater Than or Equal to 90 Days 330 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Maternity Care: Elective Delivery or Early Induction Without Medical Indication at >= 37

and < 39 Weeks 335 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Maternity Care: Post-Partum Follow-Up and Care Coordination 336 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Pain Brought Under Control within 48 Hours 342 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major

Complications (Discharged to Home by Post-Operative Day #2) 344 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --


Artery Stenting (CAS) 345 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --


Endarterectomy (CEA) 346 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured

Abdominal Aortic Aneurysms (AAA) Who Die While in Hospital 347 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

HRS-3: Implantable Cardioverter-Defibrillator (ICD) Complications Rate 348 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Optimal Vascular Care Composite 349 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging

for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines 364 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Hemoglobin A1c Test for Pediatric Patients 365 EHR Process N -- -- -- -- -- -- -- -- --

Hemoglobin A1c Test for Pediatric Patients 365 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

ADHD: Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder

(ADHD) Medication 366 EHR Process N -- -- -- -- -- -- -- -- --

Bipolar Disorder and Major Depression: Appraisal for Alcohol or Chemical Substance Use 367 EHR Process N -- -- -- -- -- -- -- -- --

HIV/AIDS: Medical Visit 368 Registry/QCDR Process N -- -- -- -- -- -- -- -- --


Pregnant Women that had HBsAg Testing 369 EHR Process N -- -- -- -- -- -- -- -- --

Pregnant Women that had HBsAg Testing 369 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Depression Remission at Twelve Months 370 EHR Outcome N -- -- -- -- -- -- -- -- --

Maternal Depression Screening 372 EHR Process N -- -- -- -- -- -- -- -- --

Functional Status Assessment for Hip Replacement 376 EHR Process N -- -- -- -- -- -- -- -- --

Functional Status Assessment for Complex Chronic Conditions 377 EHR Process N -- -- -- -- -- -- -- -- --

Children Who Have Dental Decay or Cavities 378 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

ADE Prevention and Monitoring: Warfarin Time in Therapeutic Range 380 EHR Outcome N -- -- -- -- -- -- -- -- --

HIV/AIDS: RNA Control for Patients with HIV 381 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Adult Primary Rhegmatogenous Retinal Detachment Repair Success Rate 384 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Adult Primary Rhegmatogenous Retinal Detachment Surgery Success Rate 385 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences 386 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users 387 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Discussion and Shared Decision Making Surrounding Treatment Options 390 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

HRS-9: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED)

Implantation, Replacement, or Revision 393 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Immunizations for Adolescents 394 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Lung Cancer Reporting (Resection Specimens) 396 Claims Process N -- -- -- -- -- -- -- -- --

Lung Cancer Reporting (Resection Specimens) 396 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Optimal Asthma Control 398 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Screening for Hepatocellular Carcinoma (HCC) in patients with Hepatitis C Cirrhosis 401 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Appropriate Testing for Children with Pharyngitis 66 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Hematology: Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in Patients

Receiving Erythropoietin Therapy 68 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Hematology: Multiple Myeloma: Treatment with Bisphosphonates 69 Registry/QCDR Process N -- -- -- -- -- -- -- -- --


Receptor (ER/PR) Positive Breast Cancer 71 EHR Process N -- -- -- -- -- -- -- -- --

Colon Cancer: Chemotherapy for AJCC Stage III Colon Cancer Patients 72 Claims Process N -- -- -- -- -- -- -- -- --

Colon Cancer: Chemotherapy for AJCC Stage III Colon Cancer Patients 72 EHR Process N -- -- -- -- -- -- -- -- --

Colon Cancer: Chemotherapy for AJCC Stage III Colon Cancer Patients 72 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Adult Kidney Disease: Hemodialysis Adequacy: Solute 81 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Adult Kidney Disease: Peritoneal Dialysis Adequacy: Solute 82 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Documentation of the Consent Process for Subcutaneous Allergen Immunotherapy in the

Medical Record AAAAI 10 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Asthma Assessment and Classification AAAAI 11 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Lung Function/Spirometry Evaluation AAAAI 12 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Influenza Immunization AAAAI 13 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Patient Self-Management and Action Plan AAAAI 14 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Body Mass Index AAAAI 15 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Optimal Asthma Control AAAAI 16 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Asthma Control: Minimal Important Difference Improvement AAAAI 17 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Penicillin Allergy: Appropriate Removal or Confirmation AAAAI 18 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Asthma: Assessment of Asthma Control - Ambulatory Care Setting AAAAI 2 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Allergen Immunotherapy Treatment: Allergen Specific Immunoglobulin E (IgE) Sensitivity

Assessed and Documented Prior to Treatment AAAAI 5 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Documentation of Clinical Response to Allergen Immunotherapy within One Year AAAAI 6 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Documented Rationale to Support Long-Term Aeroallergen Immunotherapy Beyond Five

Years, as Indicated AAAAI 7 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Achievement of Projected Effective Dose of Standardized Allergens for Patient Treated

With Allergen Immunotherapy for at Least One Year AAAAI 8 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Assessment of Asthma Symptoms Prior to Administration of Allergen Immunotherapy

Injection(s) AAAAI 9 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Anesthesia: Patient Experience Survey ABG 12 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Malignant Hyperthermia ABG 13 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Corneal Abrasion ABG 14 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

PACU Intubation Rate ABG 4 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Composite Procedural Safety for All Vascular Access Procedures ABG 5 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Rate of Unplanned Use of Difficult Airway Equipment and/or Failed Airway ABG 6 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Immediate Adult Post-Operative Pain Management ABG 7 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Use of Checklist for Transfer of Care From Anesthesia Provider ABG 8 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged

18 Years and Older ACEP 1 Registry/QCDR Process N -- -- -- -- -- -- -- -- --


tPA Considered ACEP 14 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Antibiotic Prescribed for Adult Acute Sinusitis ACEP 16 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis ACEP 18 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Gout: Serum Urate Target ACR 7 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Gout: ULT Therapy ACR 8 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Median Size Specific Dose Estimate for CT Chest without contrast(single phase scan) ACRad 10 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Median Dose Length Product for CT Chest without contrast (singlephase scan) ACRad 11 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Median Size Specific Dose Estimate for CT Abdomen-Pelvis withContrast (single phase

scan) ACRad 12 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Median Dose Length Product for CT Abdomen-pelvis with contrast(single phase scan) ACRad 13 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Report Turnaround Time: Radiography ACRad 15 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Report Turnaround Time: Ultrasound (Excluding Breast US) ACRad 16 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Report Turnaround Time: MRI ACRad 17 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Report Turnaround Time: CT ACRad 18 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Report Turnaround Time: PET ACRad 19 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

CT Colonography Clinically Significant Extracolonic Findings ACRad 2 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Lung Cancer Screening Abnormal Interpretation Rate ACRad 23 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Screening Mammography Node Negativity Rate ACRad 7 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Screening Mammography Minimal Cancer Rate ACRad 8 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Median Dose Length Product for CT Head/Brain without contrast(single phase scan) ACRad 9 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Prophylactic Antibiotics in Abdominal Trauma ACS 1 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Risk Standardized Decubitus Ulcer Rate within 30 Days Following Operation ACS 10 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Discontinuation of Prophylactic Antibiotics in Abdominal Trauma ACS 2 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Venous Thromboembolism (VTE) Prophylaxis in Trauma Patients ACS 3 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections in Elective

CVC Insertions following Trauma ACS 4 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Documentation of Anticoagulation Use in the Medical Record ACS 5 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Documentation of Glasgow Coma Score at Time of Initial Evaluation ACS 6 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Risk Standardized Mortality Rate within 30 Days Following Trauma Operation ACS 7 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Risk Standardized Pneumonia Rate within 30 Days Following Operation ACS 8 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Risk Standardized Urinary Tract Infection Rate within 30 Days Following Operation ACS 9 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Colonoscopy Assessment (Procedure adequacy) - Assessment of Bowel Preparation AGACCSSR 1 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Colonoscopy Assessment (Cecum reached) - Cecal Intubation / Depth of Intubation AGACCSSR 2 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Hospital Visit Rate After Outpatient Colonoscopy AGACCSSR 3 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Performance of Upper Endoscopic Examination With Colonoscopy AGACCSSR 4 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Unnecessary Screening Colonoscopy in Older Adults AGACCSSR 5 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Coronary Artery Bypass Graft (CABG): Stroke AQI 19 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --


Artery Endarterectomy (CAE) AQI 22 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Rate of Endovascular aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured

Abdominal Aortic Aneurysms (AAA) Who Die While in Hospital AQI 23 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation AQI 24 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Unplanned Hospital Readmission within 30 Days of Principal Proceure AQI 26 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Surgical Site Infection AQI 27 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Cardiac Stress Nuclear Imaging Not Meeting Appropriate Use Criteria: Preoperative

Evaluation in Low Risk Surgery Patients ASNC 1 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Nuclear cardiology imaging studies terminated due to technical problems ASNC 10 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Overall study quality ASNC 11 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Cardiac Stress Nuclear Imaging Not Meeting Appropriate Use Criteria: Routine Testing

After Percutaneous Coronary Intervention (PCI) ASNC 2 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Cardiac Stress Nuclear Imaging Not Meeting Appropriate Use Criteria: Testing in

Asymptomatic, Low-Risk Patients ASNC 3 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Utilization of standardized nomenclature and reporting for nuclear cardiology imaging

studies ASNC 4 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Single-Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging

(MPI) study report turnaround time < 24 hours ASNC 5 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Nucelar cardiac stress imaging not meeting appropriate use criteria ASNC 7 Registry/QCDR Process N -- -- -- -- -- -- -- -- --


Laboratory accreditation for nuclear cardiology imaging studies ASNC 8 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Physician reader is CBNC certified in nuclear cardiology ASNC 9 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Hemoglobin or hematrocrit measurement for patients receiving discretionary

intraoperative red blood cell transfusions ASPIRE 12 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Transfusion goal of hematocrit less than 30 ASPIRE 13 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Administration of insulin or glucose recheck for patients with hyperglycemia ASPIRE 4 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Administration of dextrose containing solution or glucose recheck for patients with

perioperative glucose < 60 ASPIRE 5 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Diabetic Foot Ulcer (DFU) Healing or Closure CDR 2 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Venous Leg Ulcer outcome measure: Healing or Closure CDR 6 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Plan of Care for Venous Leg Ulcer Patients not Achieving 30% Closure at 4 Weeks CDR 7 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Appropriate use of hyperbaric oxygen therapy for patients with diabetic foot ulcers CDR 8 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Appropriate use of Cellular or Tissue Based Products (CTP) for patients aged 18 years or

older with a diabetic foot ulcer (DFU) or venous leg ulcer (VLU) CDR 9 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Door to Diagnostic Evaluation by a Provider - All Emergency Department (ED) Patients ECPR 1 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Mean Time from Emergency Department (ED) Arrival to ED Departure for Pediatric ED

Patients Placed into Inpatient or Observation Status ECPR 10 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Door to Diagnostic Evaluation by a Provider - Adult Emergency Department (ED) Patients ECPR 2 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Computerized Tomography (CT) for Acute Sinusitis (Overuse) ECPR 22 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Door to Diagnostic Evaluation by a Provider - Pediatric Emergency Department (ED)

Patients ECPR 3 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Mean Time from Emergency Department (ED) Arrival to ED Departure for All Discharged

ED Patients ECPR 4 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Mean Time from Emergency Department (ED) Arrival to ED Departure for Discharged

Lower Acuity ED Patients ECPR 5 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Mean Time from Emergency Department (ED) Arrival to ED Departure for Discharged

Higher Acuity ED Patients ECPR 6 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Mean Time from Emergency Department (ED) Arrival to ED Departure for All ED Patients

Placed into Inpatient or Observation Status ECPR 8 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Mean Time from Emergency Department (ED) Arrival to ED Departure for Adult ED

Patients Placed into Inpatient or Observation Status ECPR 9 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Helicobacter pylori (H. pylori) status rate GIQIC 11 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Mean Time from Emergency Department (ED) Arrival to ED Departure for All ED Patients

Placed into Inpatient or Observation Status HCPR 1 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Mean Length of Stay for Inpatients - All Patients HCPR 2 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Mean Length of Stay for Inpatients - Pneumonia HCPR 3 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Mean Length of Stay for Inpatients - CHF HCPR 4 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Mean Length of Stay for Inpatients - COPD HCPR 5 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

30 Day All Cause Re-Admission Rate for All Discharged Inpatients HCPR 6 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

30 Day All Cause Re-Admission Rate Following Pneumonia Hospitalization HCPR 7 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

30 Day All Cause Re-Admission Rate Following CHF Hospitalization HCPR 8 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

30 Day All Cause Re-Admission Rate Following COPD Hospitalization HCPR 9 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Corneal Graft: 20/40 or Better Visual Acuity within 90 Days following Corneal Graft

Surgery IRIS 1 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Exudative Age-Related Macular Degeneration: Loss of Visual Acuity IRIS 10 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Age-Related Macular Degeneration: Disease Progression IRIS 12 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Diabetic Macular Edema: Loss of Visual Acuity IRIS 13 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Rhegmatogenous Retinal Detachment Surgery: Visual acuity improvement within 90 days

of surgery IRIS 14 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Rhegmatogenous Retinal Detachment Surgery: Return to the operating room within 90

days of surgery IRIS 15 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Acute Anterior Uveitis: Post-treatment visual acuity IRIS 16 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Acute Anterior Uveitis: Post-treatment Grade 0 anterior chamber cells IRIS 17 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Chronic Anterior Uveitis: Post-treatment visual acuity IRIS 18 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Chronic Anterior Uveitis: Post-treatment Grade 0 anterior chamber cells IRIS 19 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Open-Angle Glaucoma: Intraocular Pressure Reduction IRIS 2 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Open-Angle Glaucoma: Visual Field Progression IRIS 3 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Open-Angle Glaucoma: Intraocular Pressure Reduction Following Laser Trabeculoplasty IRIS 4 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --


Acquired Involutional Ptosis: Improvement of Marginal Reflex Distance within 90 Days

Following Surgery for Acquired Involutional Ptosis IRIS 5 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Acquired Involutional Entropion: Normalization of Eyelid Position within 90 Days

Following Surgery for Acquired Involutional Entropion IRIS 6 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Amblyopia: Improvement of Corrected Interocular Visual Acuity Difference to 2 or fewer

Lines IRIS 7 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Surgical Esotropia: Patients with Postoperative Alignment of 15 PD or less IRIS 8 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Diabetic Retinopathy: Dilated Eye Exam IRIS 9 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Procedures with statin and antiplatelet agents prescribed at discharge M2S 1 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Imaging-based maximum aortic diameter assessed at one-year following Endovascular

AAA Repair procedures M2S 11 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Ipsilateral stroke-free survival at one-year following isolated CEA for asymptomatic

procedures M2S 8 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Imaging-based maximum aortic diameter assessed at one-year following Thoracic and

Complex EVAR procedures M2S 9 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Medical Complications MBS 1 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Surgical Site Complications MBS 2 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Serious Complications MBS 3 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

MBSC Venous Thromboembolism prophylaxis adherence rates for Perioperative Care MBS 4 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

MBSC Venous Thromboembolism prophylaxis adherence rates for Postoperative Care MBS 5 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

MBSC Venous Thromboembolism prophylaxis adherence rates for Post-discharge Care MBS 6 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Extended Length of Stay (LOS) MBS 7 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Unplanned Emergency Room (ER) visits MBS 8 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Unplanned Hospital Readmission within 30 Days of Principal Procedure MBS 9 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Prostate Cancer: Avoidance of Overuse of CT Scan for Staging Low Risk Prostate Cancer

Patients: MUSIC 3 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Prostate Cancer: Proportion of patients with low-risk prostate cancer receiving active

surveillance MUSIC 4 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Prostate Cancer: Percentage of prostate cancer cases with a length of stay > 2 days MUSIC 5 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Unplanned Hospital Readmission within 30 Days of Radical Prostatectomy: MUSIC 6 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Prostate Biopsy: Proportion of patients undergoing a repeat prostate biopsy within 12

months of their initial biopsy in the registry as a result of a finding of atypical small acinar

proliferation (ASAP) as per the NCCN guidelines MUSIC 9 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Unplanned Reoperation Following Spine Procedure Within the 30 Day Post Operative

Period NPA 10 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Unplanned Readmission Following Spine Procedure Within the 30 Day Post Operative

Period NPA 11 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Risk -assessment for elective spine procedure NPA 15 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Participation in a Systematic National Database for Spine Care Interventions NPA 21 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Functional Outcome Assessment for Spine Intervention NPA 3 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Quality of Life Assessment for Spine Intervention NPA 4 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Patient Satisfaction with Spine Care NPA 5 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Spine?related procedure site infection NPA 6 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Complication Following Spine?Related Procedure NPA 7 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Hospital Mortality following Spine Procedure NPA 8 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Back Pain: Mental Health Assessment OBERD 1 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Quality of Life (VR--12 or Promis Global 10) Monitoring OBERD 10 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

CG--?CAHPS Adult Visit Composite Tracking OBERD 12 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Orthopedic Functional and Pain Level Outcomes OBERD 13 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

CG?CAHPS Patient Rating OBERD 17 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Back Pain: Patient Reassessment OBERD 2 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Pain Assessment and Follow--Up OBERD 4 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Back Pain: Surgical Timing OBERD 5 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

30 day Readmission for Acute Myocardial Infarction PInc 1 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

30 day Readmission for Heart Failure PInc 2 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Thrombolytic Therapy PInc 21 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Discharged on Statin Medication PInc 22 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Stroke Education PInc 23 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Venous Thromboembolism (VTE) Prophylaxis PInc 24 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

ICU VTE Prophylaxis PInc 25 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

VTE Patients With Anticoagulation Overlap Therapy PInc 26 Registry/QCDR Process N -- -- -- -- -- -- -- -- --


VTE Warfarin Therapy Discharge Instructions PInc 27 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Tobacco Use Treatment Provided or Offered PInc 28 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Median Time from ED Arrival to ED Departure for Admitted ED Patients PInc 29 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

30 day Readmission for Pneumonia PInc 3 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Admit Decision Time to ED Departure Time for Admitted Patients PInc 30 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Median Time from ED Arrival to ED Departure for Discharged ED Patients PInc 31 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Door to Diagnostic Evaluation by a Qualified Medical Professional PInc 32 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Risk-Adjusted Average Length of Inpatient Hospital Stay for Acute Myocardial Infarction

(AMI) PInc 33 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Risk-Adjusted Average Length of Inpatient Hospital Stay for Heart Failure (HF) PInc 34 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Risk-Adjusted Average Length of Inpatient Hospital Stay for Pneumonia (PN) PInc 35 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

30 day Mortality for Acute Myocardial Infarction PInc 4 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

30 day Mortality for Heart Failure PInc 5 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

30 day Mortality for Pneumonia PInc 6 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Heart Failure (HF): ACEI or ARB Therapy PPRNET 10 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Heart Failure (HF): Beta-Blocker Therapy PPRNET 11 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Appropriate Treatment for Adults with Upper Respiratory Infection PPRNET 24 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Appropriate Antibiotic Use PPRNET 25 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Use of Benzodiazepines in the Elderly PPRNET 27 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Perioperative Care: Timely Administration of Prophylactic Parenteral Antibiotics QUANTUM 1 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Medication Error by Anesthesia Care Team QUANTUM 13 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Anaphylaxis QUANTUM 14 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Aspiration of Gastric Contents QUANTUM 15 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Surgical Fire QUANTUM 16 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Immediate Perioperative Cardiac Arrest QUANTUM 17 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Unplanned Hospital Admission QUANTUM 19 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Unplanned ICU Admission QUANTUM 20 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Anesthesiology: Post Anesthetic Transfer of Care Measure: Use of Checklist or Protocol for

Direct Transfer of Care from OR or Procedure Room to the Post Anesthesia Care Unit

(PACU) QUANTUM 22 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Anesthesiology: Post Anesthetic Transfer of Care Measure: Use of Checklist or Protocol for

Direct Transfer of Care from OR or Procedure Room to Intensive Care Unit (ICU) QUANTUM 23 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Surgical Case Cancellation QUANTUM 24 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Use of a Postoperative Nausea and Vomiting Risk Protocol aged 18 years or older QUANTUM 28 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Difficult Intubation due to unrecognized difficult airway QUANTUM 4 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Dental Damage/Loss QUANTUM 8 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Angiotensin Converting Enzyme (ACE) Inhibitor or AngiotensinReceptor Blocker (ARB)

Therapy(PCPI Measure #: AKID-2) RPAQIR 1 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

CABG- Short postoperative LOS (SLOS) STS 2 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

CABG + Valve- Short postoperative length of stay (SLOS) STS 4 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Isolated Valve- Short postoperative LOS (SLOS) STS 6 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

Patient Centered surgical risk assessment and communication using the STS Risk

Calculator STS 7 Registry/QCDR Process N -- -- -- -- -- -- -- -- --

Healing or Closure of Wagner Grade 3, 4 or 5 Diabetic Foot Ulcers (DFUs) Treated with

HBOT USWR 15 Registry/QCDR Outcome N -- -- -- -- -- -- -- -- --

measure name measure id submission method … of mips_benchmark_results... · table 2: mips...

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