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Proposed Final Measure Set

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Effectiveness of Care

National Healthcare Quality Report

Cancer / Chronic Kidney Disease / Diabetes / Heart Disease / HIV/AIDS / Maternal and Child Health / Mental Health / Respiratory Diseases / Nursing Home and Home Health Care

Measure Measure Specificationsa National Databasea State Databasea
Cancer: Screening for breast cancer Process: % of women (age 40 and over) who report they had a mammogram within the past 2 years HP2010(3-13) NHIS BRFSS
Outcome: Rate of breast cancers diagnosed at advanced stage SEER program SEER n.a.
Cancer: Screening for cervical cancer Process: % of women (age 18 and over) who report that they had a Pap smear within the past 3 years HP2010(3-11b) NHIS BRFSS
Outcome: Rate of cervical cancers diagnosed as invasive (includes local, regional, and distant disease except in situ disease) SEER program SEER n.a.
Cancer: Screening for colorectal cancer Process: % of men and women (age 50 and over) who report they ever had a flexible sigmoidoscopy/colonoscopy HP2010(3-12b) NHIS BRFSS
Process: % of men and women (age 50 and over) who report they had a fecal occult blood test (FOBT) within the past 2 years HP2010(3-12a) NHIS BRFSS
Outcome: Rate of colorectal cancers diagnosed as regional or distant staged cancers SEER program SEER n.a.
Cancer: Cancer treatment Outcome: Cancer deaths per 100,000 persons per year for all cancers HP2010(3-1) Vital statistics Vital statistics
Outcome: Cancer deaths per 100,000 persons per year for most common cancers, prostate cancer HP2010(3-7) Vital statistics Vital statistics
Outcome: Cancer deaths per 100,000 persons per year for most common cancers, breast cancer HP2010(3-3) Vital statistics Vital statistics
Outcome: Cancer deaths per 100,000 persons per year for most common cancers, lung cancer HP2010(3-2) Vital statistics Vital statistics
Outcome: Cancer deaths per 100,000 persons per year for most common cancers, colorectal cancer HP2010(3-5) Vital statistics Vital statistics
Cancer: Palliative care Esophageal resection mortality rate      
Pancreatic resection mortality rate      
Chronic Kidney Disease: Management of End Stage Renal Disease Process: % of dialysis patients registered on waiting list for transplantation HP2010 4-5 USRDS USRDS
Process: % of patients with treated chronic kidney failure who receive a transplant within three years of registration on waiting list HP2010 4-6 USRDS USRDS
Outcome: % of hemodialysis patients with URR 65 or greater From CMS, Umich Unit Specific Report, pp.3,4,5,18,21 U. Michigan U. Michigan
Outcome:% of patients with hematocrit 33 or greater From CMS, Umich Unit Specific Report, pp.3,4,5,18,21 U. Michigan U. Michigan
Outcome: Patient survival rate From CMS, Umich Unit Specific Report, pp.3,4,5,18,21 n.a. U. Michigan
Counseling for chronic kidney failure care   USRDS USRDS
Use of arteriovenous fistulas—New hemodialysis patients (aged 20 years and over)   USRDS USRDS
Diabetes: Management of diabetes Process: % of adults with diabetes who had a hemoglobin A1c measurement at least once in past year Specs for MEPS MEPS BRFSS
Process: % of patients with diabetes who had a lipid profile in past two years Specs for MEPS MEPS n.a.
Process: % of adults with diabetes who had a retinal eye examination in past year Specs for MEPS MEPS BRFSS
Process: % of adults with diabetes who had a foot examination in past year Specs for MEPS MEPS BRFSS
Process: % of adults with diabetes who had an influenza immunization in past year Specs for MEPS MEPS BRFSS
Outcome: Percent of adults with diagnosed diabetes with HbA1c level > 9% (poor control); < 7.0 (optimal) National Diabetes Quality Improvement Alliance NHANES n.a.
Outcome: % of adults with diagnosed diabetes with most recent LDL-C level < 130 mg/dL (minimally acceptable);
< 100 (optimal) [b]
National Diabetes Quality Improvement Alliance n.a. n.a.
Outcome: % of adults with diagnosed diabetes with most recent blood pressure < 140/90 mm/Hg National Diabetes Quality Improvement Alliance NHANES n.a.
Outcome: Hospital admissions for uncontrolled diabetes per 100,000 population AHRQ-QI, HCUP PQI HCUP n.a.
Outcome: Hospital admissions for short term complications of diabetes per 100,000 population AHRQ-QI, HCUP PQI HCUP n.a.
Outcome: Hospital admissions for long term complications of diabetes per 100,000 population AHRQ-QI, HCUP PQI HCUP n.a.
Outcome: Hospital admissions for lower extremity amputations in patients with diabetes per 1000 population HP 2010(5-10) NHDS n.a.
Heart Disease: Screening for high blood pressure Process: % of people age 18 and over who have had blood pressure measured within preceding 2 years and can state whether their blood pressure is normal or high HP2010 NHIS BRFSS
Heart Disease: Screening for high cholesterol Process: % of adults 18 and over receiving cholesterol measurement within 5 years HP2010(12-15) NHIS BRFSS
Heart Disease: Counseling on risk factors Process: % of smokers receiving advice to quit smoking HP2010(1-3c) MEPS BRFSS
Heart Disease: Treatment of AMI Process: % of AMI patients administered aspirin within 24 hours of admission QIO scope of work QIO QIO
Process: % of AMI patients with aspirin prescribed at discharge QIO scope of work QIO QIO
Process: % of AMI patients administered beta blocker within 24 hours of admission QIO scope of work QIO QIO
Process: % of AMI patients with beta blocker prescribed at discharge QIO scope of work QIO QIO
Process: % of AMI patients with left ventricular systolic dysfunction prescribed ACE inhibitor at discharge QIO scope of work QIO QIO
Process: % of AMI patients given smoking cessation counseling while hospitalized QIO scope of work QIO QIO
Process: Median Time to Thrombolysis. Time from arrival to initiation of a thrombolytic agent in patients with ST segment elevation or left bundle branch block (LBBB) on the electrocardiogram (ECG) performed closest to hospital arrival time QIO scope of work QIO QIO
Process: Median time to PTCA. Median time from arrival to percutaneous transluminal angioplasty (PTCA) in patients with ST segment elevation or left bundle branch block (LBBB) on the electrocardiogram (ECG) performed closest to hospital arrival time. QIO scope of work QIO QIO
Heart Disease: Treatment of acute heart failure Process: % of heart failure patients having evaluation of left ventricular ejection fraction QIO scope of work QIO QIO
Process: % of heart failure patients with left ventricular systolic dysfunction prescribed ACE inhibitor at discharge QIO scope of work QIO QIO
Heart Disease: Management of hypertension Outcome: % of people with hypertension who have blood pressure under control HP2010(12-10) NHANES n.a.
Heart Disease: Management of CHF Outcome: Hospital admissions for congestive heart failure (CHF) per 1,000 population HP2010(12-6) NHDS n.a.
Pediatric heart surgery mortality rate (number of deaths per 100 heart surgeries in patients under age 18 years)   AHRQ-IQI  
AAA repair mortality rate (number of deaths per 100 AAA repairs)   AHRQ-IQI  
CABG mortality rate (number of deaths per 100 CABG procedures)   AHRQ-IQI  
PTCA mortality rate (number of deaths per 100 PTCAs)   AHRQ-IQI  
Acute myocardial infarction (AMI) mortality rate (number of deaths per 100 discharges for AMI)   AHRQ-IQI  
Congestive heart failure (CHF) mortality rate (number of deaths per 100 discharges for CHF)   AHRQ-IQI  
HIV/AIDS: AIDS prevention Outcome: New AIDS cases per 100,000 population (age 13 and over) HP2010(13-1) CDC-AIDS n.a.
HIV/AIDS: Management of HIV/AIDS Outcome: HIV-infection deaths per 100,000 population HP2010(13-14) Vital statistics Vital statistics
Maternal and Child Health: Maternity care Process: % of pregnant women receiving prenatal care in first trimester HP2010(16-6a) Vital statistics Vital statistics
Outcome: % of liveborn infants with low and very low birthweight (less than 2,500 grams, less than 1,500 grams) HP2010(16-10) Vital statistics Vital statistics
Outcome: Infant mortality per 1,000 live births HP2010(16-1c) Vital statistics Vital statistics
Outcome: Maternal deaths per 100,000 live births HP2010(16-4) Vital statistics Vital statistics
Maternal and Child Health: Immunization, childhood Process: % of children 19-35 months who received all recommended vaccines HP2010(14-24a) NIS NIS
Maternal and Child Health: Immunization, adolescent Process: % of adolescents (age 13-15) reported to have received 3 or more doses of hepatitis B vaccine HP2010(14-27a) NHIS n.a.
Process: % of adolescents (age 13-15) reported to have received 2 or more doses of MMR vaccine HP2010(14-27b) NHIS n.a.
Process: % of adolescents (age 13-15) reported to have received 1 or more doses of tetanus-diphtheria booster HP2010(14-27c) NHIS n.a.
Process: % of adolescents (age 13-15) reported to have received 3 or more doses of varicella vaccine HP2010(14-27d) NHIS n.a.
Maternal and Child Health: Childhood dental care Process: % of children age 2-17 who report dental visit in last year HP 2010(21-10) MEPS n.a.
Maternal and Child Health: Treatment of pediatric gastroenteritis Outcome: Hospital admissions for pediatric gastroenteritis per 100,000 population less than 18 years of age AHRQ-PQI, HCUP PQI HCUP n.a.
Maternal and Child Health: Childhood preventive care Whether the doctor or other health professional measured height and weight of child MEPS MEPS n.a.
Whether the doctor or other health professional gave advice about amount and kind of physical activity MEPS MEPS n.a.
Has a doctor or other health provider ever given you or (PERSON) advice about (PERSON) eating healthy? MEPS MEPS n.a.
Whether the doctor or other health professional checked for vision. MEPS MEPS n.a.
Whether the doctor or other health professional gave advice to parent or guardian about how smoking in the house can be harmful (i.e., passive smoking question) MEPS MEPS n.a.
Whether the doctor or other health professional gave advice about using child car safety seat OR booster seat OR lap and shoulder belts (age appropriate questions asked) MEPS MEPS n.a.
Whether the doctor or other health professional recommended using a helmet while riding a bike or motorcycle MEPS MEPS n.a.
Mental Health: Treatment of depression Process: % of adults diagnosed with a new episode of depression who had optimal practitioner contacts for medication management during the acute treatment phase HEDIS HEDIS n.a.
Process: % of adults diagnosed with a new episode of depression and initiated on an antidepressant drug who received a continuous trial of medication treatment during the acute treatment phase HEDIS HEDIS n.a.
Process: % of adults diagnosed with a new episode of depression and initiated on an antidepressant drug who remained on an antidepressant medication through the continuation phase of treatment HEDIS HEDIS n.a.
Outcome: Deaths due to suicide per 100,000 population HP2010(18-1) Vital statistics Vital statistics
Respiratory Diseases: Immunization, influenza Process: % of high risk persons (e.g. COPD) age 18-64 who received an influenza vaccination in the past 12 months HP2010(14-29c) NHIS BRFSS
Process: % of persons age 65 and over who received an influenza vaccination in the past 12 months HP2010(14-29a) NHIS BRFSS
Process: % of institutionalized adults (persons in long-term care or nursing homes) who received influenza vaccination in past 12 months HP2010(14-29e) NNHS n.a.
Outcome: Hospital admissions for immunization-preventable influenza per 100,000 population HP2010(1-9c, approximate) AHRQ-PQI HCUP n.a.
Respiratory Diseases: Immunization, pneumonia Process: % of high risk persons (e.g. COPD) age 18-64 who ever received a pneumococcol vaccination HP2010(14-29d) NHIS BRFSS
Process: % of persons age 65 and over who ever received a pneumococcol vaccination HP2010(14-29b) NHIS BRFSS
Process: % of institutionalized adults (persons in long-term care or nursing homes) who ever received pneumococcol vaccination HP2010(14-29f) NNHS n.a.
Respiratory Diseases: Treatment of pneumonia Process: % of patients with pneumonia who have blood cultures collected before antibiotics are administered QIO scope of work n.a. QIO
Process: percent of patients with pneumonia who receive the initial antibiotic dose within 4 hours of hospital arrival QIO scope of work n.a. QIO
Process: % of patients with pneumonia who receive the initial antibiotic consistent with current recommendations QIO scope of work n.a. QIO
Process: % of patients with pneumonia who receive influenza screening or vaccination QIO scope of work n.a. QIO
Process: % of patients with pneumonia who receive pneumococcal screening or vaccination QIO scope of work n.a. QIO
Pneumonia mortality rate (number of deaths per 1,000 discharges for pneumonia) AHRQ-IQI AHRQ-IQI n.a.
Respiratory Diseases: Treatment of URI Process: % of visits where antibiotic was prescribed for the diagnosis of a common cold, children & Adults HP2010(14-19) NAMCS-NHAMCS n.a.
Respiratory Diseases: Management of asthma Process: % of people with persistent asthma who are prescribed medications acceptable as primary therapy for long-term control of asthma (inhaled corticosteroids) HEDIS HEDIS n.a.
Outcome: Hospital admissions for pediatric asthma per 10,000 population under age 18 HP2010(24-2, 1-9a) NHDS n.a.
Outcome: Hospital admissions for asthma per 10,000 population HP2010(24-2) NHDS n.a.
Outcome: Hospital admissions for asthma per 100,000 population age 65 and over AHRQ-PQI HCUP n.a.
Respiratory Diseases: Treatment of TB Process: Percent of TB patients that complete a curative course of TB treatment within 12 months of initiation of treatment   CDC, TB n.a.
Nursing Home and Home Health Care: Nursing facility care Percent of residents whose need for help with daily activities has increased CMS n.a. MDS
Percent of residents who have moderate to severe pain CMS n.a. MDS
Percent of residents who were physically restrained CMS n.a. MDS
Percent of residents who spent most of their time in bed or in a chair CMS n.a. MDS
Percent of residents whose ability to move about in and around their room got worse CMS n.a. MDS
Percent of residents with a urinary tract infection CMS n.a. MDS
Percent of residents who have become more depressed or anxious CMS n.a. MDS
Percent of high risk residents who have pressure sores CMS n.a. MDS
Percent of low risk residents who have pressure sores CMS n.a. MDS
Percent of low risk residents who lose control of their bowels or bladder CMS n.a. MDS
Percent of residents who have/had a catheter inserted and left in their bladder CMS n.a. MDS
Percent of short stay residents who had moderate to severe pain CMS n.a. MDS
Percent of short stay residents with delirium CMS n.a. MDS
Percent of short stay residents with pressure sores CMS n.a. MDS
Nursing Home and Home Health Care: Home health care Outcome: improvement in upper body dressing CMS n.a. OASIS
Outcome: improvement in management of oral medications CMS n.a. OASIS
Outcome: improvement in bathing CMS n.a. OASIS
Outcome: stabilization in bathing CMS n.a. OASIS
Outcome: improvement in transferring CMS n.a. OASIS
Outcome: improvement in ambulation/locomotion CMS n.a. OASIS
Outcome: improvement in toileting CMS n.a. OASIS
Outcome: improvement in pain interfering with activity CMS n.a. OASIS
Outcome: improvement in dyspnea CMS n.a. OASIS
Outcome: improvement in urinary incontinence CMS n.a. OASIS
Outcome: improvement in confusion frequency CMS n.a. OASIS
Outcome: acute care hospitalization CMS n.a. OASIS

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