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| Measure_Name | Measure_ID | Submission_Method | Measure_Type | Benchmark | Standard_Deviation | Average | Decile_3 | Decile_4 | Decile_5 | Decile_6 | Decile_7 | Decile_8 | Decile_9 | Decile_10 | TOPPED_OUT | SevenPointCap_PY18 | Topped_Out_PY2017 | Topped_Out_PY2018 |
| Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) | 1 | Claims | Outcome | Y | 21.7 | 22 | 33.33 - 23.54 | 23.53 - 18.25 | 18.24 - 14.30 | 14.29 - 11.55 | 11.54 - 8.90 | 8.89 - 6.26 | 6.25 - 3.34 | <= 3.33 | No | No | -- | -- |
| Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) | 1 | EHR | Outcome | Y | 29.3 | 49.4 | 83.10 - 67.96 | 67.95 - 54.09 | 54.08 - 43.22 | 43.21 - 34.12 | 34.11 - 27.28 | 27.27 - 21.75 | 21.74 - 15.74 | <= 15.73 | No | No | -- | -- |
| Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) | 1 | Registry/QCDR | Outcome | Y | 27.1 | 34.8 | 57.89 - 42.37 | 42.36 - 31.59 | 31.58 - 25.78 | 25.77 - 20.94 | 20.93 - 16.82 | 16.81 - 12.78 | 12.77 - 7.70 | <= 7.69 | No | No | -- | -- |
| Diabetes: Low Density Lipoprotein (LDL) Management | 2 | EHR | Outcome | Y | 18.6 | 39.7 | 23.91 - 30.91 | 30.92 - 36.79 | 36.80 - 41.92 | 41.93 - 46.01 | 46.02 - 50.19 | 50.20 - 54.96 | 54.97 - 61.53 | >= 61.54 | No | No | -- | -- |
| Diabetes: Low Density Lipoprotein (LDL) Management | 2 | Registry/QCDR | Outcome | Y | 21.6 | 22.2 | 2.25 - 2.85 | 2.86 - 4.34 | 4.35 - 17.05 | 17.06 - 27.50 | 27.51 - 37.08 | 37.09 - 44.28 | 44.29 - 52.98 | >= 52.99 | No | 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 | 21.5 | 64.6 | 43.53 - 53.26 | 53.27 - 62.85 | 62.86 - 68.74 | 68.75 - 72.40 | 72.41 - 77.91 | 77.92 - 85.18 | 85.19 - 91.33 | >= 91.34 | No | 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 | 11.8 | 87.1 | 79.25 - 82.92 | 82.93 - 85.52 | 85.53 - 88.88 | 88.89 - 91.66 | 91.67 - 94.43 | 94.44 - 96.76 | 96.77 - 99.99 | 100.00 | No | No | -- | -- |
| Coronary Artery Disease (CAD): Antiplatelet Therapy | 6 | Registry/QCDR | Process | Y | 11.7 | 87.3 | 81.22 - 84.94 | 84.95 - 87.49 | 87.50 - 89.56 | 89.57 - 91.61 | 91.62 - 93.34 | 93.35 - 95.80 | 95.81 - 99.99 | 100.00 | No | No | -- | -- |
| Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%) | 7 | EHR | Process | Y | 23.1 | 74.8 | 51.35 - 68.22 | 68.23 - 78.77 | 78.78 - 82.64 | 82.65 - 86.32 | 86.33 - 90.79 | 90.80 - 94.25 | 94.26 - 97.60 | >= 97.61 | No | No | -- | -- |
| Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%) | 7 | Registry/QCDR | Process | Y | 15.2 | 84.2 | 72.55 - 79.06 | 79.07 - 84.43 | 84.44 - 88.51 | 88.52 - 91.17 | 91.18 - 94.28 | 94.29 - 98.03 | 98.04 - 99.99 | 100.00 | No | No | -- | -- |
| Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) | 8 | EHR | Process | Y | 19.6 | 73.2 | 60.00 - 65.78 | 65.79 - 70.58 | 70.59 - 74.99 | 75.00 - 79.99 | 80.00 - 85.95 | 85.96 - 90.47 | 90.48 - 95.99 | >= 96.00 | No | No | -- | -- |
| Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) | 8 | Registry/QCDR | Process | Y | 8.5 | 91.1 | 83.83 - 87.49 | 87.50 - 90.62 | 90.63 - 93.09 | 93.10 - 95.44 | 95.45 - 97.13 | 97.14 - 99.99 | -- | 100.00 | No | No | -- | -- |
| Anti-Depressant Medication Management | 9 | EHR | Process | Y | 32.1 | 70.7 | 54.90 - 69.89 | 69.90 - 80.35 | 80.36 - 85.86 | 85.87 - 88.56 | 88.57 - 90.71 | 90.72 - 92.96 | 92.97 - 96.53 | >= 96.54 | No | No | -- | -- |
| Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation | 12 | Claims | Process | Y | 11.3 | 96.5 | 98.99 - 99.99 | -- | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation | 12 | EHR | Process | Y | 16.7 | 88.2 | 82.75 - 87.40 | 87.41 - 90.76 | 90.77 - 93.62 | 93.63 - 96.16 | 96.17 - 97.87 | 97.88 - 98.96 | 98.97 - 99.99 | 100.00 | No | No | -- | -- |
| Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation | 12 | Registry/QCDR | Process | Y | 12.8 | 95 | 94.70 - 98.14 | 98.15 - 99.16 | 99.17 - 99.99 | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Age-Related Macular Degeneration (AMD): Dilated Macular Examination | 14 | Claims | Process | Y | 11.7 | 97 | 99.60 - 99.99 | -- | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Age-Related Macular Degeneration (AMD): Dilated Macular Examination | 14 | Registry/QCDR | Process | Y | 28.7 | 80.9 | 64.21 - 81.81 | 81.82 - 90.85 | 90.86 - 95.69 | 95.70 - 98.64 | 98.65 - 99.99 | -- | -- | 100.00 | Yes | No | -- | -- |
| Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy | 18 | EHR | Process | Y | 21.1 | 73.5 | 57.14 - 65.83 | 65.84 - 72.72 | 72.73 - 78.21 | 78.22 - 83.12 | 83.13 - 88.17 | 88.18 - 92.30 | 92.31 - 96.32 | >= 96.33 | No | No | -- | -- |
| Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care | 19 | Claims | Process | Y | 13.1 | 96.6 | -- | -- | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care | 19 | EHR | Process | Y | 25 | 66.8 | 46.15 - 56.85 | 56.86 - 65.13 | 65.14 - 72.38 | 72.39 - 78.21 | 78.22 - 84.27 | 84.28 - 89.93 | 89.94 - 95.41 | >= 95.42 | No | No | -- | -- |
| Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care | 19 | Registry/QCDR | Process | Y | 29.9 | 76.5 | 52.00 - 72.40 | 72.41 - 81.47 | 81.48 - 90.76 | 90.77 - 96.54 | 96.55 - 99.99 | -- | -- | 100.00 | No | No | -- | -- |
| Perioperative Care: Selection of Prophylactic Antibiotic - First OR Second Generation Cephalosporin | 21 | Claims | Process | Y | 17.4 | 94.5 | 99.13 - 99.99 | -- | -- | -- | -- | -- | -- | 100.00 | Yes | Yes | Yes | Yes |
| Perioperative Care: Selection of Prophylactic Antibiotic - First OR Second Generation Cephalosporin | 21 | Registry/QCDR | Process | Y | 11.5 | 96.6 | 98.09 - 99.99 | -- | -- | -- | -- | -- | -- | 100.00 | Yes | Yes | Yes | Yes |
| Perioperative Care: Discontinuation of Prophylactic Parenteral Antibiotics (Non-Cardiac Procedures) | 22 | Claims | Process | Y | 8.7 | 98.4 | -- | -- | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Perioperative Care: Discontinuation of Prophylactic Parenteral Antibiotics (Non-Cardiac Procedures) | 22 | Registry/QCDR | Process | Y | 10.2 | 97.3 | 98.59 - 99.99 | -- | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) | 23 | Claims | Process | Y | 11.7 | 97.3 | -- | -- | -- | -- | -- | -- | -- | 100.00 | Yes | Yes | Yes | Yes |
| Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) | 23 | Registry/QCDR | Process | Y | 14.8 | 94.8 | 95.49 - 99.72 | 99.73 - 99.99 | -- | -- | -- | -- | -- | 100.00 | Yes | Yes | Yes | Yes |
| Communication with the Physician or Other Clinician Managing On-going Care Post-Fracture for Men and Women Aged 50 Years and Older | 24 | Claims | Process | Y | 24.7 | 85 | 78.43 - 90.90 | 90.91 - 94.28 | 94.29 - 96.29 | 96.30 - 97.66 | 97.67 - 99.99 | -- | -- | 100.00 | Yes | No | -- | -- |
| Communication with the Physician or Other Clinician Managing On-going Care Post-Fracture for Men and Women Aged 50 Years and Older | 24 | Registry/QCDR | Process | Y | 38 | 50.1 | 9.29 - 18.57 | 18.58 - 28.56 | 28.57 - 36.05 | 36.06 - 60.92 | 60.93 - 86.66 | 86.67 - 99.99 | -- | 100.00 | No | No | -- | -- |
| Stroke and Stroke Rehabilitation: Discharged on Antithrombotic Therapy | 32 | Claims | Process | Y | 8.2 | 96.6 | 96.15 - 98.03 | 98.04 - 99.99 | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Stroke and Stroke Rehabilitation: Discharged on Antithrombotic Therapy | 32 | Registry/QCDR | Process | Y | 17.3 | 90.7 | 84.78 - 91.06 | 91.07 - 95.23 | 95.24 - 97.44 | 97.45 - 99.19 | 99.20 - 99.99 | -- | -- | 100.00 | Yes | No | -- | -- |
| Screening for Osteoporosis for Women Aged 65-85 Years of Age | 39 | Claims | Process | Y | 27.1 | 54.4 | 29.30 - 38.45 | 38.46 - 45.60 | 45.61 - 52.33 | 52.34 - 60.39 | 60.40 - 69.94 | 69.95 - 81.57 | 81.58 - 95.67 | >= 95.68 | No | No | -- | -- |
| Screening for Osteoporosis for Women Aged 65-85 Years of Age | 39 | Registry/QCDR | Process | Y | 31.6 | 51.5 | 13.36 - 29.05 | 29.06 - 47.01 | 47.02 - 55.92 | 55.93 - 65.41 | 65.42 - 73.07 | 73.08 - 82.50 | 82.51 - 92.30 | >= 92.31 | No | No | -- | -- |
| Osteoporosis: Pharmacologic Therapy for Men and Women Aged 50 Years and Older | 41 | Claims | Process | Y | 30 | 64.1 | 35.19 - 41.26 | 41.27 - 48.27 | 48.28 - 58.81 | 58.82 - 77.26 | 77.27 - 97.13 | 97.14 - 99.99 | -- | 100.00 | No | No | -- | -- |
| Osteoporosis: Pharmacologic Therapy for Men and Women Aged 50 Years and Older | 41 | Registry/QCDR | Process | Y | 20.9 | 68.6 | 55.71 - 62.15 | 62.16 - 66.66 | 66.67 - 69.51 | 69.52 - 73.57 | 73.58 - 79.02 | 79.03 - 84.99 | 85.00 - 98.94 | >= 98.95 | No | No | -- | -- |
| Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) in Patients with Isolated CABG Surgery | 43 | Registry/QCDR | Process | Y | 2.1 | 99 | 98.51 - 99.14 | 99.15 - 99.99 | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery | 44 | Registry/QCDR | Process | Y | 9.9 | 95.2 | 94.44 - 96.11 | 96.12 - 97.23 | 97.24 - 98.72 | 98.73 - 99.99 | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Medication Reconciliation Post-Discharge | 46 | Claims | Process | Y | 15 | 95 | 96.15 - 98.50 | 98.51 - 99.99 | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Medication Reconciliation Post-Discharge | 46 | Registry/QCDR | Process | Y | 16 | 94.2 | 96.15 - 99.43 | 99.44 - 99.99 | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Care Plan | 47 | Claims | Process | Y | 38.6 | 67.1 | 18.63 - 36.26 | 36.27 - 68.14 | 68.15 - 93.72 | 93.73 - 98.73 | 98.74 - 99.99 | -- | -- | 100.00 | No | No | -- | -- |
| Care Plan | 47 | Registry/QCDR | Process | Y | 31.6 | 73.2 | 44.99 - 66.16 | 66.17 - 77.69 | 77.70 - 86.58 | 86.59 - 93.74 | 93.75 - 97.69 | 97.70 - 99.59 | 99.60 - 99.99 | 100.00 | No | No | -- | -- |
| Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older | 48 | Claims | Process | Y | 40.7 | 68 | 9.49 - 37.92 | 37.93 - 81.64 | 81.65 - 98.04 | 98.05 - 99.99 | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older | 48 | Registry/QCDR | Process | Y | 31.6 | 70.2 | 41.23 - 59.05 | 59.06 - 71.69 | 71.70 - 81.47 | 81.48 - 89.32 | 89.33 - 95.82 | 95.83 - 99.31 | 99.32 - 99.99 | 100.00 | No | No | -- | -- |
| Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older | 50 | Claims | Process | Y | 26.7 | 87.2 | 85.00 - 94.73 | 94.74 - 98.52 | 98.53 - 99.99 | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older | 50 | Registry/QCDR | Process | Y | 19.6 | 90.5 | 87.50 - 93.54 | 93.55 - 97.43 | 97.44 - 99.99 | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation | 51 | Claims | Process | Y | 37.4 | 70.9 | 21.74 - 52.37 | 52.38 - 81.81 | 81.82 - 95.82 | 95.83 - 99.99 | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation | 51 | Registry/QCDR | Process | Y | 22.5 | 80.7 | 69.23 - 77.00 | 77.01 - 82.97 | 82.98 - 87.94 | 87.95 - 93.32 | 93.33 - 95.69 | 95.70 - 98.36 | 98.37 - 99.99 | 100.00 | No | No | -- | -- |
| Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator Therapy | 52 | Claims | Process | Y | 13.1 | 96.4 | 99.03 - 99.99 | -- | -- | -- | -- | -- | -- | 100.00 | Yes | Yes | Yes | Yes |
| Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator Therapy | 52 | Registry/QCDR | Process | Y | 17.1 | 91 | 84.21 - 93.97 | 93.98 - 96.14 | 96.15 - 97.81 | 97.82 - 99.99 | -- | -- | -- | 100.00 | Yes | Yes | Yes | Yes |
| Emergency Medicine: 12-Lead Electrocardiogram (ECG) Performed for Non-Traumatic Chest Pain | 54 | Claims | Process | Y | 6.1 | 97.1 | 95.71 - 97.16 | 97.17 - 98.10 | 98.11 - 98.81 | 98.82 - 99.99 | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Emergency Medicine: 12-Lead Electrocardiogram (ECG) Performed for Non-Traumatic Chest Pain | 54 | Registry/QCDR | Process | Y | 11.3 | 94.5 | 92.86 - 95.94 | 95.95 - 97.26 | 97.27 - 98.31 | 98.32 - 98.86 | 98.87 - 99.62 | 99.63 - 99.99 | -- | 100.00 | Yes | No | -- | -- |
| Appropriate Treatment for Children with Upper Respiratory Infection (URI) | 65 | EHR | Process | Y | 16.6 | 85.4 | 74.00 - 82.42 | 82.43 - 87.90 | 87.91 - 91.29 | 91.30 - 93.99 | 94.00 - 95.99 | 96.00 - 98.92 | 98.93 - 99.99 | 100.00 | No | No | -- | -- |
| Appropriate Treatment for Children with Upper Respiratory Infection (URI) | 65 | Registry/QCDR | Process | Y | 17.8 | 88.7 | 74.19 - 89.18 | 89.19 - 93.54 | 93.55 - 99.99 | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Appropriate Testing for Children with Pharyngitis | 66 | EHR | Process | Y | 26.8 | 65.4 | 43.33 - 56.18 | 56.19 - 66.66 | 66.67 - 74.74 | 74.75 - 80.51 | 80.52 - 84.43 | 84.44 - 87.29 | 87.30 - 91.88 | >= 91.89 | No | No | -- | -- |
| Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenetic Testing Performed on Bone Marrow | 67 | Registry/QCDR | Process | Y | 7.2 | 98.1 | -- | -- | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Hematology: Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in Patients Receiving Erythropoietin Therapy | 68 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Hematology: Multiple Myeloma: Treatment with Bisphosphonates | 69 | Registry/QCDR | Process | Y | 27.5 | 89.7 | -- | -- | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry | 70 | Registry/QCDR | Process | Y | 6.1 | 98 | 97.14 - 99.99 | -- | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Breast Cancer: Hormonal Therapy for Stage IC -IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer | 71 | Claims | Process | Y | 1.4 | 99.7 | -- | -- | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Breast Cancer: Hormonal Therapy for Stage IC -IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer | 71 | EHR | Process | Y | 20.2 | 85.5 | 67.27 - 89.99 | 90.00 - 93.32 | 93.33 - 94.34 | 94.35 - 97.29 | 97.30 - 97.77 | 97.78 - 99.99 | -- | 100.00 | No | No | -- | -- |
| Breast Cancer: Hormonal Therapy for Stage IC -IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer | 71 | Registry/QCDR | Process | Y | 14.8 | 94.2 | 93.62 - 99.46 | 99.47 - 99.99 | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Colon Cancer: Chemotherapy for AJCC Stage III Colon Cancer Patients | 72 | Claims | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Colon Cancer: Chemotherapy for AJCC Stage III Colon Cancer Patients | 72 | EHR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Colon Cancer: Chemotherapy for AJCC Stage III Colon Cancer Patients | 72 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections | 76 | Claims | Process | Y | 23.4 | 88.4 | 85.37 - 95.23 | 95.24 - 98.04 | 98.05 - 99.99 | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections | 76 | Registry/QCDR | Process | Y | 15.6 | 93.3 | 91.85 - 96.14 | 96.15 - 98.88 | 98.89 - 99.99 | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Acute Otitis Externa (AOE): Topical Therapy | 91 | Claims | Process | Y | 27.5 | 80.3 | 61.54 - 72.72 | 72.73 - 86.35 | 86.36 - 95.82 | 95.83 - 98.38 | 98.39 - 99.99 | -- | -- | 100.00 | Yes | No | -- | -- |
| Acute Otitis Externa (AOE): Topical Therapy | 91 | Registry/QCDR | Process | Y | 22 | 75.8 | 59.26 - 69.99 | 70.00 - 74.99 | 75.00 - 80.83 | 80.84 - 86.20 | 86.21 - 92.30 | 92.31 - 95.44 | 95.45 - 99.99 | 100.00 | No | No | -- | -- |
| Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy - Avoidance of Inappropriate Use | 93 | Claims | Process | Y | 12.6 | 93.9 | 88.37 - 95.99 | 96.00 - 97.49 | 97.50 - 99.99 | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy - Avoidance of Inappropriate Use | 93 | Registry/QCDR | Process | Y | 15.3 | 90.4 | 82.80 - 90.47 | 90.48 - 94.43 | 94.44 - 97.61 | 97.62 - 99.99 | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade | 99 | Claims | Process | Y | 2.7 | 99.3 | -- | -- | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade | 99 | Registry/QCDR | Process | Y | 2.7 | 99 | 99.39 - 99.99 | -- | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Colorectal Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade | 100 | Claims | Process | Y | 1.4 | 99.5 | -- | -- | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Colorectal Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade | 100 | Registry/QCDR | Process | Y | 1.1 | 99.6 | -- | -- | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients | 102 | Registry/QCDR | Process | Y | 4.6 | 98.3 | 98.92 - 99.99 | -- | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Prostate Cancer: Adjuvant Hormonal Therapy for High Risk or Very High Risk Prostate Cancer | 104 | Registry/QCDR | Process | Y | 10.4 | 93.7 | 84.85 - 94.11 | 94.12 - 95.87 | 95.88 - 99.99 | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Adult Major Depressive Disorder (MDD): Suicide Risk Assessment | 107 | EHR | Process | Y | 35.3 | 65.5 | 22.86 - 51.99 | 52.00 - 74.42 | 74.43 - 84.92 | 84.93 - 88.45 | 88.46 - 92.80 | 92.81 - 95.50 | 95.51 - 96.47 | >= 96.48 | No | No | -- | -- |
| Osteoarthritis (OA): Function and Pain Assessment | 109 | Claims | Process | Y | 21.6 | 90.1 | 89.34 - 96.87 | 96.88 - 98.73 | 98.74 - 99.71 | 99.72 - 99.99 | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Osteoarthritis (OA): Function and Pain Assessment | 109 | Registry/QCDR | Process | Y | 37.9 | 65.2 | 15.38 - 35.32 | 35.33 - 64.99 | 65.00 - 84.89 | 84.90 - 95.18 | 95.19 - 99.99 | -- | -- | 100.00 | No | No | -- | -- |
| Preventive Care and Screening: Influenza Immunization | 110 | Claims | Process | Y | 32.9 | 58.7 | 23.29 - 33.13 | 33.14 - 46.93 | 46.94 - 62.62 | 62.63 - 74.35 | 74.36 - 86.05 | 86.06 - 97.34 | 97.35 - 99.99 | 100.00 | No | No | -- | -- |
| Preventive Care and Screening: Influenza Immunization | 110 | EHR | Process | Y | 26.3 | 39.3 | 14.55 - 21.83 | 21.84 - 29.00 | 29.01 - 35.99 | 36.00 - 43.53 | 43.54 - 52.13 | 52.14 - 63.12 | 63.13 - 78.42 | >= 78.43 | No | No | -- | -- |
| Preventive Care and Screening: Influenza Immunization | 110 | Registry/QCDR | Process | Y | 28.9 | 55.3 | 26.89 - 40.48 | 40.49 - 49.99 | 50.00 - 57.06 | 57.07 - 64.78 | 64.79 - 73.07 | 73.08 - 82.70 | 82.71 - 96.43 | >= 96.44 | No | No | -- | -- |
| Pneumococcal Vaccination Status for Older Adults | 111 | Claims | Process | Y | 26.2 | 68.3 | 44.78 - 55.87 | 55.88 - 65.57 | 65.58 - 73.27 | 73.28 - 80.67 | 80.68 - 87.34 | 87.35 - 93.84 | 93.85 - 99.68 | >= 99.69 | No | No | -- | -- |
| Pneumococcal Vaccination Status for Older Adults | 111 | EHR | Process | Y | 28.9 | 46.3 | 15.40 - 25.61 | 25.62 - 37.30 | 37.31 - 47.48 | 47.49 - 56.46 | 56.47 - 65.52 | 65.53 - 75.08 | 75.09 - 85.70 | >= 85.71 | No | No | -- | -- |
| Pneumococcal Vaccination Status for Older Adults | 111 | Registry/QCDR | Process | Y | 28.4 | 58 | 29.93 - 45.27 | 45.28 - 55.09 | 55.10 - 62.58 | 62.59 - 69.99 | 70.00 - 76.96 | 76.97 - 83.99 | 84.00 - 92.88 | >= 92.89 | No | No | -- | -- |
| Breast Cancer Screening | 112 | Claims | Process | Y | 28.1 | 59.4 | 33.68 - 45.35 | 45.36 - 53.21 | 53.22 - 60.28 | 60.29 - 67.83 | 67.84 - 76.55 | 76.56 - 89.23 | 89.24 - 99.99 | 100.00 | No | No | -- | -- |
| Breast Cancer Screening | 112 | EHR | Process | Y | 26 | 46.3 | 19.19 - 31.97 | 31.98 - 40.58 | 40.59 - 48.40 | 48.41 - 55.73 | 55.74 - 63.12 | 63.13 - 70.05 | 70.06 - 78.94 | >= 78.95 | No | No | -- | -- |
| Breast Cancer Screening | 112 | Registry/QCDR | Process | Y | 26.1 | 60.7 | 38.69 - 52.53 | 52.54 - 60.13 | 60.14 - 65.18 | 65.19 - 70.17 | 70.18 - 76.01 | 76.02 - 82.72 | 82.73 - 92.04 | >= 92.05 | No | No | -- | -- |
| Colorectal Cancer Screening | 113 | Claims | Process | Y | 29.2 | 63.1 | 32.69 - 43.68 | 43.69 - 55.15 | 55.16 - 66.09 | 66.10 - 77.36 | 77.37 - 86.63 | 86.64 - 94.51 | 94.52 - 99.99 | 100.00 | No | No | -- | -- |
| Colorectal Cancer Screening | 113 | EHR | Process | Y | 28.9 | 44.2 | 12.61 - 23.91 | 23.92 - 34.31 | 34.32 - 44.54 | 44.55 - 54.09 | 54.10 - 63.63 | 63.64 - 73.09 | 73.10 - 83.14 | >= 83.15 | No | No | -- | -- |
| Colorectal Cancer Screening | 113 | Registry/QCDR | Process | Y | 27.1 | 61.7 | 37.55 - 53.00 | 53.01 - 59.91 | 59.92 - 66.20 | 66.21 - 73.07 | 73.08 - 79.48 | 79.49 - 86.42 | 86.43 - 93.81 | >= 93.82 | No | No | -- | -- |
| Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis | 116 | Registry/QCDR | Process | Y | 36.4 | 62.4 | 23.90 - 30.87 | 30.88 - 38.77 | 38.78 - 58.80 | 58.81 - 99.99 | -- | -- | -- | 100.00 | No | No | -- | -- |
| Diabetes: Eye Exam | 117 | Claims | Process | Y | 23 | 89.2 | 88.98 - 98.44 | 98.45 - 99.99 | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Diabetes: Eye Exam | 117 | EHR | Process | Y | 27.6 | 84.9 | 84.83 - 92.85 | 92.86 - 95.32 | 95.33 - 96.96 | 96.97 - 98.19 | 98.20 - 99.17 | 99.18 - 99.82 | 99.83 - 99.99 | 100.00 | Yes | No | -- | -- |
| Diabetes: Eye Exam | 117 | Registry/QCDR | Process | Y | 25.5 | 86.3 | 80.91 - 92.85 | 92.86 - 96.53 | 96.54 - 98.70 | 98.71 - 99.99 | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| 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 | 11.1 | 81.7 | 74.37 - 77.03 | 77.04 - 79.84 | 79.85 - 82.29 | 82.30 - 84.90 | 84.91 - 87.31 | 87.32 - 89.99 | 90.00 - 95.44 | >= 95.45 | No | No | -- | -- |
| Diabetes: Medical Attention for Nephropathy | 119 | EHR | Process | Y | 18.2 | 76 | 64.29 - 70.20 | 70.21 - 75.27 | 75.28 - 79.68 | 79.69 - 83.49 | 83.50 - 87.36 | 87.37 - 91.17 | 91.18 - 94.99 | >= 95.00 | No | No | -- | -- |
| Diabetes: Medical Attention for Nephropathy | 119 | Registry/QCDR | Process | Y | 15 | 81.4 | 72.00 - 76.58 | 76.59 - 80.84 | 80.85 - 84.02 | 84.03 - 86.91 | 86.92 - 90.09 | 90.10 - 93.23 | 93.24 - 97.66 | >= 97.67 | No | No | -- | -- |
| Adult Kidney Disease: Laboratory Testing (Lipid Profile) | 121 | Registry/QCDR | Process | Y | 31.7 | 51.4 | 18.47 - 28.94 | 28.95 - 38.84 | 38.85 - 52.51 | 52.52 - 61.89 | 61.90 - 74.99 | 75.00 - 85.18 | 85.19 - 94.60 | >= 94.61 | No | No | -- | -- |
| Adult Kidney Disease: Blood Pressure Management | 122 | Registry/QCDR | Outcome | Y | 19.3 | 84.7 | 69.20 - 79.16 | 79.17 - 90.69 | 90.70 - 95.08 | 95.09 - 96.47 | 96.48 - 97.66 | 97.67 - 98.73 | 98.74 - 99.99 | 100.00 | No | No | -- | -- |
| Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy - Neurological Evaluation | 126 | Registry/QCDR | Process | Y | 34.4 | 58.7 | 16.47 - 37.63 | 37.64 - 54.54 | 54.55 - 66.98 | 66.99 - 77.26 | 77.27 - 85.10 | 85.11 - 94.55 | 94.56 - 99.99 | 100.00 | No | No | -- | -- |
| Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention - Evaluation of Footwear | 127 | Registry/QCDR | Process | Y | 35.5 | 55 | 11.75 - 28.11 | 28.12 - 45.27 | 45.28 - 61.51 | 61.52 - 72.15 | 72.16 - 82.77 | 82.78 - 94.28 | 94.29 - 99.99 | 100.00 | No | No | -- | -- |
| Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan | 128 | Claims | Process | Y | 27.7 | 72.6 | 43.20 - 48.42 | 48.43 - 58.92 | 58.93 - 83.56 | 83.57 - 96.60 | 96.61 - 99.53 | 99.54 - 99.99 | -- | 100.00 | No | No | -- | -- |
| Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan | 128 | EHR | Process | Y | 23.5 | 45 | 28.22 - 31.92 | 31.93 - 35.34 | 35.35 - 38.76 | 38.77 - 42.88 | 42.89 - 49.18 | 49.19 - 64.83 | 64.84 - 85.93 | >= 85.94 | No | No | -- | -- |
| Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan | 128 | Registry/QCDR | Process | Y | 24.5 | 67.3 | 45.12 - 52.05 | 52.06 - 59.99 | 60.00 - 68.74 | 68.75 - 77.77 | 77.78 - 86.07 | 86.08 - 92.85 | 92.86 - 99.42 | >= 99.43 | No | No | -- | -- |
| Documentation of Current Medications in the Medical Record | 130 | Claims | Process | Y | 14 | 95.6 | 97.20 - 99.23 | 99.24 - 99.79 | 99.80 - 99.99 | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Documentation of Current Medications in the Medical Record | 130 | EHR | Process | Y | 19.1 | 89.3 | 86.25 - 91.91 | 91.92 - 94.85 | 94.86 - 96.69 | 96.70 - 97.98 | 97.99 - 98.87 | 98.88 - 99.54 | 99.55 - 99.95 | >= 99.96 | Yes | No | -- | -- |
| Documentation of Current Medications in the Medical Record | 130 | Registry/QCDR | Process | Y | 27.2 | 84.9 | 77.08 - 90.22 | 90.23 - 95.97 | 95.98 - 98.60 | 98.61 - 99.69 | 99.70 - 99.99 | -- | -- | 100.00 | Yes | No | -- | -- |
| Pain Assessment and Follow-Up | 131 | Claims | Process | Y | 25.8 | 87.2 | 79.10 - 96.36 | 96.37 - 99.37 | 99.38 - 99.91 | 99.92 - 99.99 | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Pain Assessment and Follow-Up | 131 | Registry/QCDR | Process | Y | 37.4 | 68.3 | 20.00 - 49.79 | 49.80 - 77.66 | 77.67 - 88.49 | 88.50 - 95.53 | 95.54 - 99.33 | 99.34 - 99.99 | -- | 100.00 | No | No | -- | -- |
| Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan | 134 | Claims | Process | Y | 39.6 | 65.3 | 17.13 - 29.27 | 29.28 - 65.00 | 65.01 - 91.46 | 91.47 - 99.34 | 99.35 - 99.99 | -- | -- | 100.00 | No | No | -- | -- |
| Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan | 134 | EHR | Process | Y | 32.2 | 28.4 | 0.51 - 1.29 | 1.30 - 5.09 | 5.10 - 12.51 | 12.52 - 25.60 | 25.61 - 42.30 | 42.31 - 64.36 | 64.37 - 83.73 | >= 83.74 | No | No | -- | -- |
| Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan | 134 | Registry/QCDR | Process | Y | 33.1 | 63.4 | 28.44 - 53.24 | 53.25 - 62.81 | 62.82 - 71.15 | 71.16 - 79.90 | 79.91 - 88.69 | 88.70 - 96.42 | 96.43 - 99.99 | 100.00 | No | No | -- | -- |
| Melanoma: Continuity of Care - Recall System | 137 | Registry/QCDR | Structure | Y | 20.7 | 89.9 | 87.50 - 93.64 | 93.65 - 96.96 | 96.97 - 99.99 | -- | -- | -- | -- | 100.00 | No | No | -- | -- |
| Melanoma: Coordination of Care | 138 | Registry/QCDR | Process | Y | 30.9 | 78.5 | 52.38 - 78.97 | 78.98 - 88.88 | 88.89 - 95.54 | 95.55 - 99.99 | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement | 140 | Claims | Process | Y | 14.1 | 95.2 | 97.33 - 99.99 | -- | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement | 140 | Registry/QCDR | Process | Y | 31.1 | 72.1 | 35.90 - 57.88 | 57.89 - 71.75 | 71.76 - 86.38 | 86.39 - 94.22 | 94.23 - 98.31 | 98.32 - 99.99 | -- | 100.00 | No | No | -- | -- |
| Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care | 141 | Claims | Process | Y | 12.3 | 97.4 | -- | -- | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care | 141 | Registry/QCDR | Process | Y | 28.4 | 82.9 | 69.40 - 86.96 | 86.97 - 95.04 | 95.05 - 97.95 | 97.96 - 99.64 | 99.65 - 99.99 | -- | -- | 100.00 | Yes | No | -- | -- |
| Oncology: Medical and Radiation - Pain Intensity Quantified | 143 | EHR | Process | Y | 22 | 87.6 | 82.07 - 91.90 | 91.91 - 96.54 | 96.55 - 99.07 | 99.08 - 99.86 | 99.87 - 99.99 | -- | -- | 100.00 | Yes | No | -- | -- |
| Oncology: Medical and Radiation - Pain Intensity Quantified | 143 | Registry/QCDR | Process | Y | 20.7 | 88.6 | 82.03 - 90.76 | 90.77 - 95.39 | 95.40 - 97.56 | 97.57 - 99.09 | 99.10 - 99.99 | -- | -- | 100.00 | Yes | No | -- | -- |
| Oncology: Medical and Radiation - Plan of Care for Pain | 144 | Registry/QCDR | Process | Y | 18.5 | 91.7 | 91.74 - 97.13 | 97.14 - 98.60 | 98.61 - 99.99 | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Radiology: Exposure Dose or Time Reported for Procedures Using Fluoroscopy | 145 | Claims | Process | Y | 27.6 | 72.4 | 47.89 - 63.88 | 63.89 - 74.90 | 74.91 - 82.34 | 82.35 - 87.99 | 88.00 - 92.58 | 92.59 - 96.54 | 96.55 - 99.99 | 100.00 | No | No | -- | -- |
| Radiology: Exposure Dose or Time Reported for Procedures Using Fluoroscopy | 145 | Registry/QCDR | Process | Y | 21.7 | 83.6 | 71.91 - 81.24 | 81.25 - 87.09 | 87.10 - 91.66 | 91.67 - 95.68 | 95.69 - 98.67 | 98.68 - 99.99 | -- | 100.00 | No | No | -- | -- |
| Radiology: Inappropriate Use of "Probably Benign" Assessment Category in Screening Mammograms | 146 | Claims | Process | Y | 0.8 | 0.2 | 0.23 - 0.01 | -- | -- | -- | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| Radiology: Inappropriate Use of "Probably Benign" Assessment Category in Screening Mammograms | 146 | Registry/QCDR | Process | Y | 3.6 | 0.5 | 0.31 - 0.05 | 0.04 - 0.01 | -- | -- | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy | 147 | Claims | Structure | Y | 23.5 | 82.4 | 66.67 - 79.16 | 79.17 - 87.49 | 87.50 - 93.23 | 93.24 - 96.54 | 96.55 - 99.99 | -- | -- | 100.00 | No | No | -- | -- |
| Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy | 147 | Registry/QCDR | Structure | Y | 16.2 | 90.3 | 83.67 - 90.71 | 90.72 - 95.41 | 95.42 - 97.82 | 97.83 - 99.99 | -- | -- | -- | 100.00 | No | No | -- | -- |
| Falls: Risk Assessment | 154 | Claims | Process | Y | 19.3 | 93.1 | 96.84 - 99.99 | -- | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Falls: Risk Assessment | 154 | Registry/QCDR | Process | Y | 30.7 | 77.4 | 49.22 - 72.83 | 72.84 - 84.61 | 84.62 - 95.23 | 95.24 - 99.88 | 99.89 - 99.99 | -- | -- | 100.00 | Yes | No | -- | -- |
| Falls: Plan of Care | 155 | Claims | Process | Y | 32.9 | 75.7 | 42.25 - 61.32 | 61.33 - 87.64 | 87.65 - 98.89 | 98.90 - 99.99 | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Falls: Plan of Care | 155 | Registry/QCDR | Process | Y | 32.7 | 76.5 | 46.15 - 75.12 | 75.13 - 89.18 | 89.19 - 94.16 | 94.17 - 97.32 | 97.33 - 99.99 | -- | -- | 100.00 | No | No | -- | -- |
| Oncology: Radiation Dose Limits to Normal Tissues | 156 | Registry/QCDR | Process | Y | 5.8 | 97.5 | 95.87 - 98.94 | 98.95 - 99.99 | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis | 160 | EHR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Diabetes: Foot Exam | 163 | EHR | Process | Y | 28.8 | 38.6 | 9.38 - 16.32 | 16.33 - 24.01 | 24.02 - 31.57 | 31.58 - 44.65 | 44.66 - 59.08 | 59.09 - 69.43 | 69.44 - 79.71 | >= 79.72 | No | No | -- | -- |
| Diabetes: Foot Exam | 163 | Registry/QCDR | Process | Y | 26.8 | 68.7 | 47.85 - 55.21 | 55.22 - 68.09 | 68.10 - 72.45 | 72.46 - 83.44 | 83.45 - 89.76 | 89.77 - 94.64 | 94.65 - 98.10 | >= 98.11 | No | No | -- | -- |
| Coronary Artery Bypass Graft (CABG): Prolonged Intubation | 164 | Registry/QCDR | Outcome | Y | 5.3 | 7.7 | 12.39 - 9.87 | 9.86 - 8.74 | 8.73 - 6.80 | 6.79 - 5.35 | 5.34 - 4.23 | 4.22 - 3.04 | 3.03 - 1.35 | <= 1.34 | No | No | -- | -- |
| Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate | 165 | Registry/QCDR | Outcome | Y | 0.8 | 0.4 | 0.54 - 0.01 | -- | -- | -- | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| Coronary Artery Bypass Graft (CABG): Stroke | 166 | Registry/QCDR | Outcome | Y | 1.9 | 1.4 | 2.53 - 1.86 | 1.85 - 1.36 | 1.35 - 0.88 | 0.87 - 0.01 | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure | 167 | Registry/QCDR | Outcome | Y | 2.2 | 2.1 | 3.74 - 2.79 | 2.78 - 2.18 | 2.17 - 1.68 | 1.67 - 1.19 | 1.18 - 0.01 | -- | -- | 0.00 | Yes | No | -- | -- |
| Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration | 168 | Registry/QCDR | Outcome | Y | 2.5 | 2.5 | 3.85 - 3.29 | 3.28 - 2.68 | 2.67 - 2.06 | 2.05 - 1.50 | 1.49 - 0.95 | 0.94 - 0.01 | -- | 0.00 | No | No | -- | -- |
| Rheumatoid Arthritis (RA): Functional Status Assessment | 178 | Registry/QCDR | Process | Y | 32.2 | 75.4 | 48.99 - 68.70 | 68.71 - 81.07 | 81.08 - 92.77 | 92.78 - 96.03 | 96.04 - 99.59 | 99.60 - 99.99 | -- | 100.00 | No | No | -- | -- |
| Elder Maltreatment Screen and Follow-Up Plan | 181 | Claims | Process | Y | 36.2 | 81.9 | 82.12 - 99.60 | 99.61 - 99.99 | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Elder Maltreatment Screen and Follow-Up Plan | 181 | Registry/QCDR | Process | Y | 30.6 | 76.5 | 51.20 - 75.53 | 75.54 - 83.75 | 83.76 - 90.28 | 90.29 - 95.70 | 95.71 - 98.97 | 98.98 - 99.99 | -- | 100.00 | No | No | -- | -- |
| Functional Outcome Assessment | 182 | Claims | Process | Y | 16.8 | 96 | 99.95 - 99.99 | -- | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Functional Outcome Assessment | 182 | Registry/QCDR | Process | Y | 24.4 | 91.3 | 94.95 - 97.20 | 97.21 - 99.77 | 99.78 - 99.99 | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Colonoscopy Interval for Patients with a History of Adenomatous Polyps.- Avoidance of Inappropriate Use | 185 | Claims | Process | Y | 6.5 | 97.7 | 98.00 - 99.99 | -- | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Colonoscopy Interval for Patients with a History of Adenomatous Polyps.- Avoidance of Inappropriate Use | 185 | Registry/QCDR | Process | Y | 14.9 | 93.2 | 90.91 - 95.99 | 96.00 - 97.49 | 97.50 - 99.64 | 99.65 - 99.99 | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Stroke and Stroke Rehabilitation: Thrombolytic Therapy | 187 | Registry/QCDR | Outcome | Y | 28.5 | 69.9 | 52.63 - 57.47 | 57.48 - 63.88 | 63.89 - 71.00 | 71.01 - 80.55 | 80.56 - 96.52 | 96.53 - 99.99 | -- | 100.00 | No | No | -- | -- |
| Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery | 191 | EHR | Outcome | Y | 16.2 | 88.1 | 83.33 - 88.82 | 88.83 - 91.81 | 91.82 - 94.11 | 94.12 - 95.69 | 95.70 - 96.88 | 96.89 - 97.98 | 97.99 - 99.31 | >= 99.32 | No | No | -- | -- |
| Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery | 191 | Registry/QCDR | Outcome | Y | 20.4 | 85.6 | 75.68 - 84.91 | 84.92 - 91.10 | 91.11 - 94.35 | 94.36 - 96.46 | 96.47 - 97.79 | 97.80 - 99.99 | -- | 100.00 | No | No | -- | -- |
| Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures | 192 | EHR | Outcome | Y | 1.4 | 0.3 | 0.33 - 0.01 | -- | -- | -- | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures | 192 | Registry/QCDR | Outcome | Y | 0.8 | 0.4 | 0.50 - 0.18 | 0.17 - 0.01 | -- | -- | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| Radiology: Stenosis Measurement in Carotid Imaging Reports | 195 | Claims | Process | Y | 17.1 | 90.6 | 85.94 - 92.58 | 92.59 - 95.91 | 95.92 - 97.99 | 98.00 - 99.46 | 99.47 - 99.99 | -- | -- | 100.00 | Yes | No | -- | -- |
| Radiology: Stenosis Measurement in Carotid Imaging Reports | 195 | Registry/QCDR | Process | Y | 10.1 | 95 | 91.92 - 96.04 | 96.05 - 98.27 | 98.28 - 99.99 | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet | 204 | Claims | Process | Y | 8.9 | 89.7 | 83.87 - 86.90 | 86.91 - 89.00 | 89.01 - 90.90 | 90.91 - 92.65 | 92.66 - 94.58 | 94.59 - 97.01 | 97.02 - 99.99 | 100.00 | No | No | -- | -- |
| Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet | 204 | EHR | Process | Y | 20.1 | 67.6 | 53.33 - 61.75 | 61.76 - 68.32 | 68.33 - 73.23 | 73.24 - 77.10 | 77.11 - 80.60 | 80.61 - 83.91 | 83.92 - 87.92 | >= 87.93 | No | No | -- | -- |
| Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet | 204 | Registry/QCDR | Process | Y | 14.5 | 84.1 | 76.89 - 81.70 | 81.71 - 84.61 | 84.62 - 87.16 | 87.17 - 89.51 | 89.52 - 91.87 | 91.88 - 94.89 | 94.90 - 99.99 | 100.00 | No | No | -- | -- |
| HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis | 205 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Functional Status Change for Patients with Knee Impairments | 217 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Functional Status Change for Patients with Hip Impairments | 218 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Functional Status Change for Patients with Foot or Ankle Impairments | 219 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Functional Status Change for Patients with Lumbar Impairments | 220 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Functional Status Change for Patients with Shoulder Impairments | 221 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Functional Status Change for Patients with Elbow, Wrist or Hand Impairments | 222 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Functional Status Change for Patients with General Orthopaedic Impairments | 223 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Melanoma: Overutilization of Imaging Studies in Melanoma | 224 | Registry/QCDR | Process | Y | 5.4 | 99.5 | -- | -- | -- | -- | -- | -- | -- | 100.00 | Yes | Yes | Yes | Yes |
| Radiology: Reminder System for Screening Mammograms | 225 | Claims | Structure | Y | 21.7 | 91.6 | 94.20 - 98.22 | 98.23 - 99.67 | 99.68 - 99.99 | -- | -- | -- | -- | 100.00 | No | No | -- | -- |
| Radiology: Reminder System for Screening Mammograms | 225 | Registry/QCDR | Structure | Y | 10.5 | 97.4 | -- | -- | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | 226 | Claims | Process | Y | 7.9 | 97.4 | 96.65 - 98.59 | 98.60 - 99.61 | 99.62 - 99.99 | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | 226 | EHR | Process | Y | 20.2 | 82.7 | 72.72 - 82.40 | 82.41 - 87.55 | 87.56 - 90.50 | 90.51 - 92.74 | 92.75 - 94.63 | 94.64 - 96.52 | 96.53 - 98.51 | >= 98.52 | No | No | -- | -- |
| Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | 226 | Registry/QCDR | Process | Y | 15.4 | 88.8 | 83.72 - 88.38 | 88.39 - 91.10 | 91.11 - 93.34 | 93.35 - 95.44 | 95.45 - 97.35 | 97.36 - 99.00 | 99.01 - 99.99 | 100.00 | No | No | -- | -- |
| Controlling High Blood Pressure | 236 | Claims | Process | Y | 18.1 | 71.4 | 58.02 - 63.90 | 63.91 - 68.36 | 68.37 - 72.91 | 72.92 - 76.91 | 76.92 - 81.65 | 81.66 - 86.95 | 86.96 - 94.06 | >= 94.07 | No | No | -- | -- |
| Controlling High Blood Pressure | 236 | EHR | Process | Y | 17.5 | 61.7 | 51.10 - 56.51 | 56.52 - 60.77 | 60.78 - 64.28 | 64.29 - 67.46 | 67.47 - 70.93 | 70.94 - 74.88 | 74.89 - 80.42 | >= 80.43 | No | No | -- | -- |
| Controlling High Blood Pressure | 236 | Registry/QCDR | Process | Y | 18.7 | 68.1 | 56.36 - 62.91 | 62.92 - 67.53 | 67.54 - 70.68 | 70.69 - 73.78 | 73.79 - 77.45 | 77.46 - 82.12 | 82.13 - 88.58 | >= 88.59 | No | No | -- | -- |
| Use of High-Risk Medications in the Elderly | 238 | EHR | Process | Y | 9.4 | 6.2 | 12.02 - 6.84 | 6.83 - 3.53 | 3.52 - 1.50 | 1.49 - 0.49 | 0.48 - 0.01 | -- | -- | 0.00 | Yes | No | -- | -- |
| Use of High-Risk Medications in the Elderly | 238 | Registry/QCDR | Process | Y | 9.7 | 6.4 | 11.54 - 7.33 | 7.32 - 4.11 | 4.10 - 1.94 | 1.93 - 0.77 | 0.76 - 0.24 | 0.23 - 0.01 | -- | 0.00 | Yes | No | -- | -- |
| Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents | 239 | EHR | Process | Y | 13.9 | 30.3 | 21.69 - 26.09 | 26.10 - 28.86 | 28.87 - 30.47 | 30.48 - 31.76 | 31.77 - 32.65 | 32.66 - 33.32 | 33.33 - 40.77 | >= 40.78 | No | No | -- | -- |
| Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents | 239 | Registry/QCDR | Process | Y | 3.9 | 31.7 | 29.13 - 30.88 | 30.89 - 31.54 | 31.55 - 32.03 | 32.04 - 32.28 | 32.29 - 32.44 | 32.45 - 32.90 | 32.91 - 33.32 | >= 33.33 | No | No | -- | -- |
| Childhood Immunization Status | 240 | EHR | Process | Y | 18.4 | 22 | 4.35 - 8.84 | 8.85 - 11.95 | 11.96 - 16.16 | 16.17 - 23.80 | 23.81 - 31.25 | 31.26 - 38.79 | 38.80 - 50.87 | >= 50.88 | No | No | -- | -- |
| Cardiac Rehabilitation Patient Referral from an Outpatient Setting | 243 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Barrett's Esophagus | 249 | Claims | Structure | Y | 1.4 | 99.8 | -- | -- | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Barrett's Esophagus | 249 | Registry/QCDR | Structure | Y | 2.4 | 99.5 | -- | -- | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Radical Prostatectomy Pathology Reporting | 250 | Registry/QCDR | Structure | Y | 4.7 | 98.1 | 97.28 - 99.99 | -- | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Quantitative Immunohistochemical (IHC) Evaluation of Human Epidermal Growth Factor Receptor 2 Testing (HER2) for Breast Cancer Patients | 251 | Claims | Structure | Y | 0.3 | 100 | -- | -- | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Quantitative Immunohistochemical (IHC) Evaluation of Human Epidermal Growth Factor Receptor 2 Testing (HER2) for Breast Cancer Patients | 251 | Registry/QCDR | Structure | Y | 3.2 | 99 | -- | -- | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain | 254 | Registry/QCDR | Process | Y | 2.2 | 99.2 | 99.51 - 99.99 | -- | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure | 255 | Claims | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure | 255 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Statin Therapy at Discharge after Lower Extremity Bypass (LEB) | 257 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Rate of Open Repair of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #7) | 258 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post Operative Day #2) | 259 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2) | 260 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness | 261 | Claims | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness | 261 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Image Confirmation of Successful Excision of Image-Localized Breast Lesion | 262 | Registry/QCDR | Process | Y | 0.6 | 99.9 | -- | -- | -- | -- | -- | -- | -- | 100.00 | Yes | Yes | Yes | Yes |
| Preoperative Diagnosis of Breast Cancer | 263 | Registry/QCDR | Process | Y | 1.4 | 99.3 | 98.98 - 99.99 | -- | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Sentinel Lymph Node Biopsy for Invasive Breast Cancer | 264 | Registry/QCDR | Process | Y | 8.1 | 97.7 | 97.87 - 98.98 | 98.99 - 99.99 | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Biopsy Follow-Up | 265 | Registry/QCDR | Process | Y | 29.7 | 81.6 | 66.67 - 85.70 | 85.71 - 92.58 | 92.59 - 97.80 | 97.81 - 99.99 | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy | 268 | Claims | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy | 268 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Sparing Therapy | 270 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related Iatrogenic Injury - Bone Loss Assessment | 271 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Inflammatory Bowel Disease (IBD): Testing for Latent Tuberculosis (TB) Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy | 274 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy | 275 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Sleep Apnea: Assessment of Sleep Symptoms | 276 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Dementia: Staging of Dementia | 280 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Dementia: Cognitive Assessment | 281 | EHR | Process | Y | 30.9 | 63.6 | 33.33 - 52.77 | 52.78 - 59.08 | 59.09 - 69.41 | 69.42 - 77.77 | 77.78 - 86.89 | 86.90 - 95.23 | 95.24 - 99.99 | 100.00 | No | No | -- | -- |
| Dementia: Functional Status Assessment | 282 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Parkinson's Disease: Psychiatric Symptoms Assessment for Patients with Parkinson's Disease | 290 | Registry/QCDR | Outcome | Y | 17.4 | 87.1 | 75.76 - 80.76 | 80.77 - 94.86 | 94.87 - 95.44 | 95.45 - 96.66 | 96.67 - 99.09 | 99.10 - 99.99 | -- | 100.00 | No | No | -- | -- |
| Parkinson’s Disease: Querying about Sleep Disturbances | 292 | Registry/QCDR | Outcome | Y | 26.1 | 80.1 | 60.53 - 79.99 | 80.00 - 86.10 | 86.11 - 90.47 | 90.48 - 95.79 | 95.80 - 97.43 | 97.44 - 99.99 | -- | 100.00 | No | No | -- | -- |
| Cataracts: Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery | 303 | Registry/QCDR | Outcome | Y | 35.7 | 58.8 | 13.16 - 33.32 | 33.33 - 51.91 | 51.92 - 72.96 | 72.97 - 82.75 | 82.76 - 88.32 | 88.33 - 92.51 | 92.52 - 98.91 | >= 98.92 | No | No | -- | -- |
| Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery | 304 | Registry/QCDR | Outcome | Y | 36.7 | 57.3 | 7.69 - 29.99 | 30.00 - 49.99 | 50.00 - 68.74 | 68.75 - 80.84 | 80.85 - 86.26 | 86.27 - 92.16 | 92.17 - 99.99 | 100.00 | No | No | -- | -- |
| Initiation and Engagement of Alcohol and Other Drug Dependence Treatment | 305 | EHR | Process | Y | 5.5 | 3.6 | 0.49 - 0.65 | 0.66 - 0.77 | 0.78 - 0.89 | 0.90 - 2.10 | 2.11 - 2.71 | 2.72 - 4.06 | 4.07 - 14.48 | >= 14.49 | No | No | -- | -- |
| Cervical Cancer Screening | 309 | EHR | Process | Y | 25.7 | 34 | 8.82 - 14.57 | 14.58 - 20.88 | 20.89 - 28.29 | 28.30 - 37.64 | 37.65 - 47.75 | 47.76 - 58.15 | 58.16 - 71.63 | >= 71.64 | No | No | -- | -- |
| Cervical Cancer Screening | 309 | Registry/QCDR | Process | Y | 20.9 | 60.9 | 47.34 - 50.87 | 50.88 - 56.24 | 56.25 - 60.89 | 60.90 - 63.33 | 63.34 - 72.83 | 72.84 - 79.56 | 79.57 - 89.45 | >= 89.46 | No | No | -- | -- |
| Chlamydia Screening for Women | 310 | EHR | Process | Y | 21.1 | 34.5 | 13.89 - 19.99 | 20.00 - 28.12 | 28.13 - 32.80 | 32.81 - 38.83 | 38.84 - 48.14 | 48.15 - 55.17 | 55.18 - 63.99 | >= 64.00 | No | No | -- | -- |
| Use of Appropriate Medications for Asthma | 311 | EHR | Process | Y | 29.9 | 60 | 26.92 - 40.15 | 40.16 - 57.13 | 57.14 - 67.85 | 67.86 - 77.87 | 77.88 - 83.86 | 83.87 - 89.05 | 89.06 - 92.60 | >= 92.61 | No | No | -- | -- |
| Use of Imaging Studies for Low Back Pain | 312 | EHR | Process | Y | 14.5 | 93.4 | 90.91 - 96.96 | 96.97 - 99.99 | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Use of Imaging Studies for Low Back Pain | 312 | Registry/QCDR | Process | Y | 8.4 | 96.6 | 96.88 - 99.09 | 99.10 - 99.99 | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | 317 | Claims | Process | Y | 24.9 | 74 | 49.53 - 57.74 | 57.75 - 66.45 | 66.46 - 78.56 | 78.57 - 90.52 | 90.53 - 98.16 | 98.17 - 99.99 | -- | 100.00 | No | No | -- | -- |
| Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | 317 | EHR | Process | Y | 16 | 28.3 | 16.53 - 20.40 | 20.41 - 23.94 | 23.95 - 26.93 | 26.94 - 29.99 | 30.00 - 33.32 | 33.33 - 37.61 | 37.62 - 45.98 | >= 45.99 | No | No | -- | -- |
| Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | 317 | Registry/QCDR | Process | Y | 27.4 | 63.9 | 35.65 - 51.15 | 51.16 - 64.21 | 64.22 - 71.25 | 71.26 - 76.46 | 76.47 - 81.40 | 81.41 - 88.06 | 88.07 - 97.68 | >= 97.69 | No | No | -- | -- |
| Falls: Screening for Future Fall Risk | 318 | EHR | Process | Y | 36.3 | 50.3 | 9.14 - 20.16 | 20.17 - 33.70 | 33.71 - 48.36 | 48.37 - 65.67 | 65.68 - 81.76 | 81.77 - 93.39 | 93.40 - 98.80 | >= 98.81 | No | No | -- | -- |
| Falls: Screening for Future Fall Risk | 318 | Registry/QCDR | Process | Y | 27.6 | 51.5 | 26.81 - 30.45 | 30.46 - 37.24 | 37.25 - 50.39 | 50.40 - 58.25 | 58.26 - 68.16 | 68.17 - 74.99 | 75.00 - 95.18 | >= 95.19 | No | No | -- | -- |
| Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients | 320 | Claims | Process | Y | 15.1 | 93.3 | 91.51 - 96.40 | 96.41 - 99.99 | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients | 320 | Registry/QCDR | Process | Y | 13.2 | 91.9 | 87.30 - 91.48 | 91.49 - 94.25 | 94.26 - 96.21 | 96.22 - 98.68 | 98.69 - 99.99 | -- | -- | 100.00 | Yes | No | -- | -- |
| Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients | 322 | Registry/QCDR | Efficiency | Y | 21.1 | 6.5 | 3.45 - 0.93 | 0.92 - 0.01 | -- | -- | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI) | 323 | Registry/QCDR | Efficiency | Y | 22 | 6.6 | 0.92 - 0.01 | -- | -- | -- | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients | 324 | Registry/QCDR | Efficiency | Y | 26.8 | 13.2 | 17.89 - 2.36 | 2.35 - 0.01 | -- | -- | -- | -- | -- | 0.00 | No | No | -- | -- |
| Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions | 325 | Registry/QCDR | Process | Y | 29.5 | 82.2 | 66.67 - 82.95 | 82.96 - 91.52 | 91.53 - 98.04 | 98.05 - 99.99 | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy | 326 | Claims | Process | Y | 14 | 94.2 | 93.91 - 97.29 | 97.30 - 99.40 | 99.41 - 99.99 | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy | 326 | Registry/QCDR | Process | Y | 15.2 | 82.1 | 74.17 - 78.28 | 78.29 - 81.24 | 81.25 - 83.91 | 83.92 - 86.37 | 86.38 - 89.23 | 89.24 - 93.22 | 93.23 - 99.99 | 100.00 | No | No | -- | -- |
| Pediatric Kidney Disease: Adequacy of Volume Management | 327 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Pediatric Kidney Disease: ESRD Patients Receiving Dialysis: Hemoglobin Level < 10 g/dL | 328 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Adult Kidney Disease: Catheter Use at Initiation of Hemodialysis | 329 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Adult Kidney Disease: Catheter Use for Greater Than or Equal to 90 Days | 330 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Overuse) | 331 | Registry/QCDR | Process | Y | 38.5 | 52.5 | 90.10 - 84.63 | 84.62 - 80.59 | 80.58 - 68.67 | 68.66 - 45.11 | 45.10 - 9.10 | 9.09 - 1.23 | 1.22 - 0.01 | 0.00 | No | No | -- | -- |
| Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use) | 332 | Registry/QCDR | Process | Y | 30.6 | 60.5 | 31.58 - 48.27 | 48.28 - 54.54 | 54.55 - 61.08 | 61.09 - 68.08 | 68.09 - 83.86 | 83.87 - 95.99 | 96.00 - 99.99 | 100.00 | No | No | -- | -- |
| Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse) | 333 | Registry/QCDR | Outcome | Y | 4.1 | 1.9 | 3.57 - 1.89 | 1.88 - 0.01 | -- | -- | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| Adult Sinusitis: More than One Computerized Tomography (CT) Scan Within 90 Days for Chronic Sinusitis (Overuse) | 334 | Registry/QCDR | Outcome | Y | 3.4 | 1.6 | 3.13 - 1.40 | 1.39 - 0.40 | 0.39 - 0.01 | -- | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| Maternity Care: Elective Delivery or Early Induction Without Medical Indication at >= 37 and < 39 Weeks (Overuse) | 335 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Maternity Care: Post-Partum Follow-Up and Care Coordination | 336 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Tuberculosis (TB) Prevention for Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis Patients on a Biological Immune Response Modifier | 337 | Registry/QCDR | Process | Y | 29.8 | 78.1 | 54.21 - 79.24 | 79.25 - 87.23 | 87.24 - 91.75 | 91.76 - 95.40 | 95.41 - 96.74 | 96.75 - 99.99 | -- | 100.00 | No | No | -- | -- |
| Pain Brought Under Control Within 48 Hours | 342 | Registry/QCDR | Outcome | Y | 25.1 | 90.1 | 93.22 - 99.99 | -- | -- | -- | -- | -- | -- | 100.00 | No | No | -- | -- |
| Screening Colonoscopy Adenoma Detection Rate | 343 | Registry/QCDR | Outcome | Y | 22.2 | 51.1 | 34.48 - 38.73 | 38.74 - 43.89 | 43.90 - 48.56 | 48.57 - 53.18 | 53.19 - 59.40 | 59.41 - 67.64 | 67.65 - 83.99 | >= 84.00 | No | No | -- | -- |
| 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 | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Rate of Postoperative Stroke or Death in Asymptomatic Patients Undergoing Carotid Artery Stenting (CAS) | 345 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Rate of Postoperative Stroke or Death in Asymptomatic Patients Undergoing Carotid Endarterectomy (CEA) | 346 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) Who Die While in Hospital | 347 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| HRS-3: Implantable Cardioverter-Defibrillator (ICD) Complications Rate | 348 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Patient-Centered Surgical Risk Assessment and Communication | 358 | Registry/QCDR | Process | Y | 36.9 | 73.8 | 31.03 - 67.99 | 68.00 - 91.05 | 91.06 - 97.11 | 97.12 - 99.99 | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computed Tomography (CT) Imaging Description | 359 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | Yes | Yes | No |
| Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies | 360 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Optimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) Images Available for Patient Follow-up and Comparison Purposes | 362 | Registry/QCDR | Structure | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Optimizing Patient Exposure to Ionizing Radiation: Search for Prior Computed Tomography (CT) Studies Through a Secure, Authorized, Media-Free, Shared Archive | 363 | Registry/QCDR | Structure | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| 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 | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Hemoglobin A1c Test for Pediatric Patients | 365 | EHR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Hemoglobin A1c Test for Pediatric Patients | 365 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| ADHD: Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication | 366 | EHR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Bipolar Disorder and Major Depression: Appraisal for alcohol or chemical substance use | 367 | EHR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| HIV/AIDS: Medical Visit | 368 | EHR | Process | Y | 21.6 | 51.1 | 28.74 - 39.12 | 39.13 - 46.96 | 46.97 - 52.34 | 52.35 - 58.55 | 58.56 - 64.70 | 64.71 - 71.17 | 71.18 - 78.37 | >= 78.38 | No | No | -- | -- |
| HIV/AIDS: Medical Visit | 368 | Registry/QCDR | Process | Y | 18.8 | 79.8 | 80.00 - 81.24 | 81.25 - 82.85 | 82.86 - 84.46 | 84.47 - 86.35 | 86.36 - 87.49 | 87.50 - 89.99 | 90.00 - 91.29 | >= 91.30 | No | No | -- | -- |
| Pregnant women that had HBsAg testing | 369 | EHR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Pregnant women that had HBsAg testing | 369 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Depression Remission at Twelve Months | 370 | EHR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Depression Remission at Twelve Months | 370 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Depression Utilization of the PHQ-9 Tool | 371 | EHR | Process | Y | 22.9 | 13.9 | 1.65 - 2.45 | 2.46 - 3.32 | 3.33 - 4.32 | 4.33 - 5.59 | 5.60 - 8.32 | 8.33 - 14.99 | 15.00 - 48.14 | >= 48.15 | No | No | -- | -- |
| Maternal Depression Screening | 372 | EHR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Hypertension: Improvement in Blood Pressure | 373 | EHR | Outcome | Y | 17.3 | 33.1 | 17.07 - 22.21 | 22.22 - 27.26 | 27.27 - 32.32 | 32.33 - 37.88 | 37.89 - 42.85 | 42.86 - 48.47 | 48.48 - 55.99 | >= 56.00 | No | No | -- | -- |
| Closing the Referral Loop: Receipt of Specialist Report | 374 | EHR | Process | Y | 29.6 | 45.3 | 14.29 - 24.13 | 24.14 - 33.57 | 33.58 - 43.65 | 43.66 - 54.33 | 54.34 - 63.78 | 63.79 - 74.99 | 75.00 - 88.63 | >= 88.64 | No | No | -- | -- |
| Closing the Referral Loop: Receipt of Specialist Report | 374 | Registry/QCDR | Process | Y | 25 | 87.8 | 65.22 - 99.99 | -- | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Functional Status Assessment for Total Knee Replacement | 375 | EHR | Process | Y | 28.8 | 37.2 | 5.08 - 14.80 | 14.81 - 25.76 | 25.77 - 36.51 | 36.52 - 44.73 | 44.74 - 51.27 | 51.28 - 60.55 | 60.56 - 79.99 | >= 80.00 | No | No | -- | -- |
| Functional Status Assessment for Total Hip Replacement | 376 | EHR | Process | Y | 28.5 | 43.9 | 10.34 - 26.08 | 26.09 - 41.66 | 41.67 - 47.82 | 47.83 - 56.50 | 56.51 - 61.15 | 61.16 - 64.99 | 65.00 - 72.72 | >= 72.73 | No | No | -- | -- |
| Functional Status Assessments for Congestive Heart Failure | 377 | EHR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Children Who Have Dental Decay or Cavities | 378 | EHR | Outcome | Y | 0.9 | 0.2 | -- | -- | -- | -- | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| Children Who Have Dental Decay or Cavities | 378 | Registry/QCDR | Outcome | Y | 1.3 | 1.2 | 1.96 - 1.34 | 1.33 - 1.08 | 1.07 - 0.94 | 0.93 - 0.49 | 0.48 - 0.43 | 0.42 - 0.23 | 0.22 - 0.19 | <= 0.18 | Yes | No | -- | -- |
| Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists | 379 | EHR | Process | Y | 3 | 2.7 | 0.36 - 0.54 | 0.55 - 0.78 | 0.79 - 1.11 | 1.12 - 2.03 | 2.04 - 4.40 | 4.41 - 5.09 | 5.10 - 7.36 | >= 7.37 | No | No | -- | -- |
| ADE Prevention and Monitoring: Warfarin Time in Therapeutic Range | 380 | EHR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| HIV/AIDS: RNA Control for Patients with HIV | 381 | EHR | Outcome | Y | 33.2 | 59.1 | 23.63 - 34.99 | 35.00 - 44.43 | 44.44 - 52.62 | 52.63 - 86.51 | 86.52 - 91.99 | 92.00 - 93.32 | 93.33 - 96.42 | >= 96.43 | No | No | -- | -- |
| Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment | 382 | EHR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Adherence to Antipsychotic Medications For Individuals with Schizophrenia | 383 | Registry/QCDR | Outcome | Y | 27 | 81.2 | 68.57 - 77.77 | 77.78 - 88.19 | 88.20 - 93.99 | 94.00 - 98.85 | 98.86 - 99.99 | -- | -- | 100.00 | No | No | -- | -- |
| Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery | 384 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery | 385 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences | 386 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users | 387 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior Capsule Requiring Unplanned Vitrectomy) | 388 | Registry/QCDR | Outcome | Y | 0.7 | 0.2 | -- | -- | -- | -- | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| Cataract Surgery: Difference Between Planned and Final Refraction | 389 | Registry/QCDR | Outcome | Y | 35.6 | 61.9 | 13.89 - 38.23 | 38.24 - 58.48 | 58.49 - 74.99 | 75.00 - 82.97 | 82.98 - 91.90 | 91.91 - 96.24 | 96.25 - 99.99 | 100.00 | No | No | -- | -- |
| Hepatitis C: Discussion and Shared Decision Making Surrounding Treatment Options | 390 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Follow-Up After Hospitalization for Mental Illness (FUH) | 391 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| HRS-9: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision | 393 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Lung Cancer Reporting (Biopsy/Cytology Specimens) | 395 | Claims | Process | Y | 11.6 | 96.9 | 96.00 - 99.99 | -- | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Lung Cancer Reporting (Biopsy/Cytology Specimens) | 395 | Registry/QCDR | Process | Y | 10.7 | 95.7 | 95.83 - 96.66 | 96.67 - 99.99 | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Lung Cancer Reporting (Resection Specimens) | 396 | Claims | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Lung Cancer Reporting (Resection Specimens) | 396 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Melanoma Reporting | 397 | Claims | Process | Y | 7.9 | 96.5 | 95.00 - 97.05 | 97.06 - 99.99 | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Melanoma Reporting | 397 | Registry/QCDR | Process | Y | 15.6 | 94.5 | 97.14 - 99.99 | -- | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Optimal Asthma Control | 398 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk | 400 | Registry/QCDR | Process | Y | 28.7 | 22.7 | 1.62 - 2.21 | 2.22 - 3.22 | 3.23 - 11.10 | 11.11 - 19.60 | 19.61 - 27.21 | 27.22 - 35.35 | 35.36 - 68.74 | >= 68.75 | No | No | -- | -- |
| Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis | 401 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Tobacco Use and Help with Quitting Among Adolescents | 402 | Registry/QCDR | Process | Y | 24.8 | 80.3 | 71.85 - 75.75 | 75.76 - 85.70 | 85.71 - 89.99 | 90.00 - 92.58 | 92.59 - 95.37 | 95.38 - 97.55 | 97.56 - 99.99 | 100.00 | No | No | -- | -- |
| Adult Kidney Disease: Referral to Hospice | 403 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Anesthesiology Smoking Abstinence | 404 | Registry/QCDR | Process | Y | 27.6 | 64.2 | 42.86 - 49.99 | 50.00 - 61.69 | 61.70 - 66.66 | 66.67 - 73.90 | 73.91 - 82.60 | 82.61 - 91.70 | 91.71 - 99.99 | 100.00 | No | No | -- | -- |
| Appropriate Follow-up Imaging for Incidental Abdominal Lesions | 405 | Claims | Process | Y | 21.2 | 18.6 | 33.33 - 22.04 | 22.03 - 15.39 | 15.38 - 11.12 | 11.11 - 7.51 | 7.50 - 4.21 | 4.20 - 1.53 | 1.52 - 0.01 | 0.00 | No | No | -- | -- |
| Appropriate Follow-up Imaging for Incidental Abdominal Lesions | 405 | Registry/QCDR | Process | Y | 21.1 | 15.5 | 25.00 - 18.19 | 18.18 - 12.39 | 12.38 - 8.71 | 8.70 - 5.09 | 5.08 - 2.23 | 2.22 - 0.01 | -- | 0.00 | No | No | -- | -- |
| Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients | 406 | Claims | Process | Y | 24.7 | 27.2 | 45.45 - 36.01 | 36.00 - 30.01 | 30.00 - 21.63 | 21.62 - 15.01 | 15.00 - 8.71 | 8.70 - 4.18 | 4.17 - 0.01 | 0.00 | No | No | -- | -- |
| Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients | 406 | Registry/QCDR | Process | Y | 27 | 20.1 | 37.32 - 21.44 | 21.43 - 15.64 | 15.63 - 6.57 | 6.56 - 4.12 | 4.11 - 1.31 | 1.30 - 0.01 | -- | 0.00 | No | No | -- | -- |
| Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia | 407 | Claims | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia | 407 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Opioid Therapy Follow-up Evaluation | 408 | Registry/QCDR | Process | Y | 23.8 | 85.9 | 75.51 - 82.66 | 82.67 - 92.01 | 92.02 - 97.78 | 97.79 - 99.99 | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Clinical Outcome Post Endovascular Stroke Treatment | 409 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Psoriasis: Clinical Response to Oral Systemic or Biologic Medications | 410 | Registry/QCDR | Outcome | Y | 31.5 | 69.7 | 40.91 - 54.54 | 54.55 - 70.82 | 70.83 - 80.30 | 80.31 - 91.50 | 91.51 - 95.64 | 95.65 - 99.99 | -- | 100.00 | No | No | -- | -- |
| Depression Remission at Six Months | 411 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Documentation of Signed Opioid Treatment Agreement | 412 | Registry/QCDR | Process | Y | 31.8 | 78.2 | 37.14 - 70.37 | 70.38 - 94.28 | 94.29 - 99.04 | 99.05 - 99.99 | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Door to Puncture Time for Endovascular Stroke Treatment | 413 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Evaluation or Interview for Risk of Opioid Misuse | 414 | Registry/QCDR | Process | Y | 28.6 | 85.5 | 79.89 - 95.34 | 95.35 - 98.23 | 98.24 - 99.99 | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older | 415 | Claims | Process | Y | 5.5 | 95.3 | 90.91 - 93.54 | 93.55 - 95.44 | 95.45 - 96.29 | 96.30 - 99.99 | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older | 415 | Registry/QCDR | Process | Y | 8.4 | 92.2 | 88.52 - 90.35 | 90.36 - 91.79 | 91.80 - 94.09 | 94.10 - 95.41 | 95.42 - 96.66 | 96.67 - 97.82 | 97.83 - 99.99 | 100.00 | No | No | -- | -- |
| Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years | 416 | Claims | Efficiency | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years | 416 | Registry/QCDR | Efficiency | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Rate of Open Repair of Small or Moderate Abdominal Aortic Aneurysms (AAA) Where Patients Are Discharged Alive | 417 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Osteoporosis Management in Women Who Had a Fracture | 418 | Registry/QCDR | Process | Y | 38.1 | 29.4 | 4.29 - 4.99 | 5.00 - 7.16 | 7.17 - 10.38 | 10.39 - 15.57 | 15.58 - 18.17 | 18.18 - 88.32 | 88.33 - 99.99 | 100.00 | No | No | -- | -- |
| Overuse Of Neuroimaging For Patients With Primary Headache And A Normal Neurological Examination | 419 | Registry/QCDR | Process | Y | 20.7 | 92.6 | 98.23 - 99.27 | 99.28 - 99.99 | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Varicose Vein Treatment with Saphenous Ablation: Outcome Survey | 420 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for Removal | 421 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury | 422 | Claims | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury | 422 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Perioperative Anti-platelet Therapy for Patients Undergoing Carotid Endarterectomy | 423 | Claims | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Perioperative Anti-platelet Therapy for Patients Undergoing Carotid Endarterectomy | 423 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Perioperative Temperature Management | 424 | Registry/QCDR | Process | Y | 13.2 | 97.2 | 99.63 - 99.99 | -- | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Photodocumentation of Cecal Intubation | 425 | Claims | Process | Y | 1.6 | 99.1 | 98.55 - 98.97 | 98.98 - 99.56 | 99.57 - 99.99 | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Photodocumentation of Cecal Intubation | 425 | Registry/QCDR | Process | Y | 29.5 | 82.3 | 63.36 - 78.52 | 78.53 - 98.58 | 98.59 - 99.99 | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit (PACU) | 426 | Registry/QCDR | Process | Y | 12.4 | 97.7 | 99.78 - 99.99 | -- | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU) | 427 | Registry/QCDR | Process | Y | 12.3 | 97.9 | -- | -- | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Pelvic Organ Prolapse: Preoperative Assessment of Occult Stress Urinary Incontinence | 428 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Pelvic Organ Prolapse: Preoperative Screening for Uterine Malignancy | 429 | Claims | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Pelvic Organ Prolapse: Preoperative Screening for Uterine Malignancy | 429 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Prevention of Post-Operative Nausea and Vomiting (PONV) - Combination Therapy | 430 | Registry/QCDR | Process | Y | 14.6 | 94.8 | 95.99 - 98.69 | 98.70 - 99.99 | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling | 431 | Registry/QCDR | Process | Y | 35.1 | 63.7 | 20.00 - 44.13 | 44.14 - 63.91 | 63.92 - 77.43 | 77.44 - 86.26 | 86.27 - 92.67 | 92.68 - 97.07 | 97.08 - 99.99 | 100.00 | No | No | -- | -- |
| Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair | 432 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse Repair | 433 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Proportion of Patients Sustaining a Ureter Injury at the Time of any Pelvic Organ Prolapse Repair | 434 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Quality of Life Assessment For Patients With Primary Headache Disorders | 435 | Claims | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Quality of Life Assessment For Patients With Primary Headache Disorders | 435 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques | 436 | Claims | Process | Y | 30 | 71.8 | 51.21 - 67.48 | 67.49 - 76.69 | 76.70 - 82.88 | 82.89 - 87.64 | 87.65 - 92.25 | 92.26 - 96.58 | 96.59 - 99.75 | >= 99.76 | No | No | -- | -- |
| Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques | 436 | Registry/QCDR | Process | Y | 23.3 | 81.2 | 64.68 - 73.79 | 73.80 - 81.51 | 81.52 - 89.00 | 89.01 - 98.20 | 98.21 - 99.99 | -- | -- | 100.00 | No | No | -- | -- |
| Rate of Surgical Conversion from Lower Extremity Endovascular Revascularization Procedure | 437 | Claims | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Rate of Surgical Conversion from Lower Extremity Endovascular Revascularization Procedure | 437 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Statin Therapy for the Prevention and Treatment of Cardiovascular Disease | 438 | Registry/QCDR | Process | Y | 12.3 | 71.2 | 61.47 - 65.40 | 65.41 - 69.31 | 69.32 - 71.67 | 71.68 - 74.37 | 74.38 - 77.21 | 77.22 - 81.17 | 81.18 - 87.22 | >= 87.23 | No | No | -- | -- |
| Age Appropriate Screening Colonoscopy | 439 | Registry/QCDR | Efficiency | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Asthma: Assessment of Asthma Control ?Ambulatory Care Setting | AAAAI2 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Allergen Immunotherapy Treatment: Allergen Specific Immunoglobulin E (IgE) Sensitivity Assessed and Documented Prior to Treatment | AAAAI5 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Documentation of Clinical Response to Allergen Immunotherapy within One Year | AAAAI6 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Documented Rationale to Support Long-Term Aeroallergen Immunotherapy Beyond Five Years, as Indicated | AAAAI7 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Achievement of Projected Effective Dose of Standardized Allergens for Patient Treated With Allergen Immunotherapy for at Least One Year | AAAAI8 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Assessment of Asthma Symptoms Prior to Administration of Allergen Immunotherapy Injection(s) | AAAAI9 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Documentation of the Consent Process for Subcutaneous Allergen Immunotherapy in the Medical Record | AAAAI10 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Asthma Assessment and Classification | AAAAI11 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Lung Function/Spirometry Evaluation | AAAAI12 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Patient Self-Management and Action Plan | AAAAI14 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Asthma Control: Minimal Important Difference Improvement | AAAAI17 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Penicillin Allergy: Appropriate Removal or Confirmation | AAAAI18 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Distal Symmetric Polyneuropathy: Prediabetes screening | AAN1 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Distal Symmetric Polyneuropathy: Screening for Unhealthy Alcohol Use | AAN2 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Epilepsy: Seizure Frequency and Seizure Intervention | AAN3 | Registry/QCDR | Intermediate Out | Y | 9.2 | 94 | 88.89 - 93.59 | 93.60 - 96.99 | 97.00 - 97.45 | 97.46 - 98.53 | 98.54 - 99.36 | 99.37 - 99.99 | -- | 100.00 | Yes | No | -- | -- |
| Epilepsy: Screening for Psychiatric or Behavioral Health Disorders | AAN4 | Registry/QCDR | Process | Y | 25.4 | 70.9 | 44.16 - 53.64 | 53.65 - 67.20 | 67.21 - 76.64 | 76.65 - 90.44 | 90.45 - 93.54 | 93.55 - 95.56 | 95.57 - 98.12 | >= 98.13 | No | No | -- | -- |
| Headache: Medication prescribed for acute migraine attack | AAN5 | Registry/QCDR | Process | Y | 16.7 | 50.9 | 39.50 - 43.47 | 43.48 - 45.29 | 45.30 - 49.99 | 50.00 - 55.81 | 55.82 - 59.60 | 59.61 - 64.72 | 64.73 - 74.09 | >= 74.10 | No | No | -- | -- |
| Headache: Overuse of Barbiturate Containing Medications for Primary Headache Disorders | AAN6 | Registry/QCDR | Process | Y | 4.5 | 97 | 94.59 - 96.47 | 96.48 - 97.87 | 97.88 - 99.26 | 99.27 - 99.73 | 99.74 - 99.99 | -- | -- | 100.00 | Yes | No | -- | -- |
| Multiple Sclerosis: Exercise and Appropriate Physical Activity Counseling for Patients with MS | AAN8 | Registry/QCDR | Process | Y | 25.8 | 34.4 | 9.62 - 11.82 | 11.83 - 18.24 | 18.25 - 29.22 | 29.23 - 42.85 | 42.86 - 53.77 | 53.78 - 59.56 | 59.57 - 67.29 | >= 67.30 | No | No | -- | -- |
| Intra-operative anesthesia safety | ABG1 | Registry/QCDR | Outcome | Y | 3.4 | 99.5 | 99.85 - 99.99 | -- | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Intra-operative Cardiac Arrest Rate | ABG2 | Registry/QCDR | Outcome | Y | 0 | 0 | -- | -- | -- | -- | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| Intra-operative Mortality Rate | ABG3 | Registry/QCDR | Outcome | Y | 0 | 0 | -- | -- | -- | -- | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| PACU tracheal intubation Rate | ABG4 | Registry/QCDR | Outcome | Y | 0 | 0 | -- | -- | -- | -- | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| Composite Procedural Safety for All Vascular Access Procedures | ABG5 | Registry/QCDR | Outcome | Y | 0 | 0 | -- | -- | -- | -- | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| Rate of Unplanned Use of Difficult Airway Equipment and/or Failed Airway | ABG6 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Immediate Adult Post-Operative Pain Management | ABG7 | Registry/QCDR | Outcome | Y | 0 | 100 | 99.93 - 99.97 | 99.98 - 99.99 | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Use of Checklist or Protocol for Transfer of Care in Phase I recovery From Anesthesia Provider to PACU or ICU | ABG8 | Registry/QCDR | Process | Y | 0.1 | 100 | -- | -- | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| OR Fire | ABG9 | Registry/QCDR | Outcome | N | 0 | 0 | -- | -- | -- | -- | -- | -- | -- | 0.00 | -- | No | -- | -- |
| Day of Surgery Case Cancellation Rate | ABG10 | Registry/QCDR | Process | Y | 0.4 | 0.1 | 0.08 - 0.01 | -- | -- | -- | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| Anaphylaxis During Anesthesia Care in the Operating Room | ABG11 | Registry/QCDR | Outcome | Y | 0 | 0 | -- | -- | -- | -- | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| Anesthesia: Patient Experience Survey | ABG12 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Malignant Hyperthermia | ABG13 | Registry/QCDR | Outcome | N | 0 | 0 | -- | -- | -- | -- | -- | -- | -- | 0.00 | -- | No | -- | -- |
| Corneal Abrasion | ABG14 | Registry/QCDR | Outcome | Y | 0 | 0 | -- | -- | -- | -- | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| Dental Injury | ABG15 | Registry/QCDR | Outcome | Y | 0 | 0 | -- | -- | -- | -- | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| Planned use of difficult airway equipment | ABG16 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Medication errors during surgery | ABG17 | Registry/QCDR | Outcome | Y | 0 | 0 | -- | -- | -- | -- | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| Pre-operative Attestation of documentation of current medications in the medical record | ABG18 | Registry/QCDR | Process | Y | 14.4 | 97.3 | -- | -- | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Unplanned hospital admission post-op, including 23 hr stay | ABG19 | Registry/QCDR | Outcome | Y | 0.1 | 0 | -- | -- | -- | -- | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| Unplanned transfer ASC to hospital | ABG20 | Registry/QCDR | Outcome | Y | 0 | 0 | -- | -- | -- | -- | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| Pre-operative OSA assessment | ABG21 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Intraoperative Airway Fire | ABG22 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Intraoperative patient fall | ABG23 | Registry/QCDR | Outcome | N | 0 | 0 | -- | -- | -- | -- | -- | -- | -- | 0.00 | -- | No | -- | -- |
| Time out error- surgical | ABG24 | Registry/QCDR | Process | N | 0 | 0 | -- | -- | -- | -- | -- | -- | -- | 0.00 | -- | No | -- | -- |
| Time out error- regional block | ABG25 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Myocardial Ischemia requiring intervention during the operative period | ABG26 | Registry/QCDR | Outcome | Y | 0 | 0 | -- | -- | -- | -- | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| Dysrhythmia requiring intervention during the operative period | ABG27 | Registry/QCDR | Outcome | Y | 0 | 0 | -- | -- | -- | -- | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| Hypertension (HTN): Blood Pressure (BP) Management | ACCPIN1 | Registry/QCDR | Outcome | Y | 8.5 | 87 | 83.41 - 85.41 | 85.42 - 87.13 | 87.14 - 88.41 | 88.42 - 89.85 | 89.86 - 91.36 | 91.37 - 92.99 | 93.00 - 94.71 | >= 94.72 | No | No | -- | -- |
| Coronary Artery Disease (CAD): Blood Pressure Control | ACCPIN2 | Registry/QCDR | Outcome | Y | 8.7 | 88.9 | 85.79 - 87.67 | 87.68 - 89.28 | 89.29 - 90.62 | 90.63 - 91.89 | 91.90 - 93.08 | 93.09 - 94.55 | 94.56 - 96.33 | >= 96.34 | No | No | -- | -- |
| HF: Patient Self Care Education | ACCPIN3 | Registry/QCDR | Process | Y | 21.3 | 77.5 | 57.81 - 71.42 | 71.43 - 78.78 | 78.79 - 84.84 | 84.85 - 89.08 | 89.09 - 92.58 | 92.59 - 95.70 | 95.71 - 98.47 | >= 98.48 | No | No | -- | -- |
| AFIB: CHA2DS2?ASc Score Risk Score Documented | ACCPIN4 | Registry/QCDR | Process | Y | 21.1 | 78.8 | 68.49 - 76.73 | 76.74 - 82.82 | 82.83 - 86.45 | 86.46 - 89.33 | 89.34 - 91.40 | 91.41 - 94.72 | 94.73 - 97.57 | >= 97.58 | No | No | -- | -- |
| CAD: Beta-blocker Therapy: Prior MI or LVSD | ACCPIN5 | Registry/QCDR | Process | Y | 8.4 | 75.7 | 69.54 - 71.78 | 71.79 - 73.70 | 73.71 - 75.50 | 75.51 - 78.00 | 78.01 - 80.23 | 80.24 - 82.94 | 82.95 - 86.42 | >= 86.43 | No | No | -- | -- |
| CAD: Cardiac Rehabilitation Patient Referral from an Outpatient Setting | ACCPIN6 | Registry/QCDR | Process | Y | 19.5 | 45.6 | 33.33 - 38.75 | 38.76 - 42.28 | 42.29 - 47.72 | 47.73 - 49.31 | 49.32 - 53.63 | 53.64 - 63.99 | 64.00 - 67.19 | >= 67.20 | No | No | -- | -- |
| Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older | ACEP19 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Coagulation Studies in Patients Presenting with Chest Pain with No Coagulopathy or Bleeding | ACEP21 | Registry/QCDR | Process | Y | 20 | 16.4 | 19.06 - 16.74 | 16.73 - 14.34 | 14.33 - 11.36 | 11.35 - 8.90 | 8.89 - 6.39 | 6.38 - 4.13 | 4.12 - 1.46 | <= 1.45 | No | No | -- | -- |
| Appropriate Emergency Department Utilization of CT for Pulmonary Embolism | ACEP22 | Registry/QCDR | Process | Y | 13.5 | 49.2 | 41.67 - 44.51 | 44.52 - 46.33 | 46.34 - 49.17 | 49.18 - 52.33 | 52.34 - 56.30 | 56.31 - 61.01 | 61.02 - 65.24 | >= 65.25 | No | No | -- | -- |
| Anti-coagulation for Acute Pulmonary Embolism Patients | ACEP23 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Pregnancy Test for Female Abdominal Pain Patients | ACEP24 | Registry/QCDR | Process | Y | 15 | 75.6 | 72.00 - 74.23 | 74.24 - 77.21 | 77.22 - 79.52 | 79.53 - 80.52 | 80.53 - 82.12 | 82.13 - 84.32 | 84.33 - 87.17 | >= 87.18 | No | No | -- | -- |
| Tobacco Screening and Cessation Intervention for ED patients with Cardiovascular and/or Pulmonary Conditions | ACEP25 | Registry/QCDR | Process | Y | 16.6 | 25.9 | 11.10 - 15.70 | 15.71 - 19.29 | 19.30 - 21.81 | 21.82 - 24.08 | 24.09 - 33.50 | 33.51 - 42.43 | 42.44 - 51.65 | >= 51.66 | No | No | -- | -- |
| Sepsis Management: Septic Shock: Lactate Level Measurement | ACEP26 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Sepsis Management: Septic Shock: Antibiotics Ordered | ACEP27 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Sepsis Management: Septic Shock: Fluid Resuscitation | ACEP28 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Disease Activity Measurement for Patients with Rheumatoid Arthritis (RA) | ACR1 | Registry/QCDR | Process | Y | 9.6 | 89.4 | 77.78 - 84.77 | 84.78 - 86.91 | 86.92 - 89.53 | 89.54 - 96.04 | 96.05 - 97.39 | 97.40 - 98.72 | 98.73 - 99.94 | >= 99.95 | No | No | -- | -- |
| Functional Status Assessment for Patients with Rheumatoid Arthritis (RA) | ACR2 | Registry/QCDR | Process | Y | 14.4 | 87.3 | 71.25 - 81.84 | 81.85 - 85.57 | 85.58 - 93.88 | 93.89 - 97.51 | 97.52 - 99.00 | 99.01 - 99.99 | -- | 100.00 | No | No | -- | -- |
| Disease-Modifying Anti-Rheumatic Drug (DMARD) Therapy for Active Rheumatoid Arthritis (RA) | ACR3 | Registry/QCDR | Process | Y | 4.9 | 92.8 | 88.93 - 90.60 | 90.61 - 93.12 | 93.13 - 94.42 | 94.43 - 95.11 | 95.12 - 95.72 | 95.73 - 96.91 | 96.92 - 97.79 | >= 97.80 | No | No | -- | -- |
| Tuberculosis Test Prior to First Course Biologic Therapy | ACR4 | Registry/QCDR | Process | Y | 10.2 | 81.1 | 71.43 - 74.99 | 75.00 - 78.56 | 78.57 - 82.59 | 82.60 - 86.04 | 86.05 - 87.49 | 87.50 - 91.17 | 91.18 - 93.64 | >= 93.65 | No | No | -- | -- |
| Glucocorticosteroids and Other Secondary Causes | ACR5 | Registry/QCDR | Process | Y | 10.3 | 82.8 | 73.66 - 79.09 | 79.10 - 81.53 | 81.54 - 84.74 | 84.75 - 88.51 | 88.52 - 89.73 | 89.74 - 92.40 | 92.41 - 94.73 | >= 94.74 | No | No | -- | -- |
| Serum Urate Monitoring | ACR6 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Gout: Serum Urate Target | ACR7 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Gout: ULT Therapy | ACR8 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| CT Colonongraphy True Positive Rate | ACRAD1 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| CT Colonography Clinically Significant Extracolonic Findings | ACRAD2 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Screening Mammography Cancer Detection Rate (CDR) | ACRAD3 | Registry/QCDR | Outcome | Y | 2.1 | 5.1 | 3.43 - 3.86 | 3.87 - 4.43 | 4.44 - 4.78 | 4.79 - 5.21 | 5.22 - 6.16 | 6.17 - 7.04 | 7.05 - 7.55 | >= 7.56 | No | No | -- | -- |
| Screening Mammography Invasive Cancer Detection Rate (ICDR) | ACRAD4 | Registry/QCDR | Outcome | Y | 2 | 4.4 | 2.67 - 3.11 | 3.12 - 3.48 | 3.49 - 3.86 | 3.87 - 4.82 | 4.83 - 5.30 | 5.31 - 5.97 | 5.98 - 7.08 | >= 7.09 | No | No | -- | -- |
| Screening Mammography Abnormal Interpretation Rate (Recall Rate) | ACRAD5 | Registry/QCDR | Outcome | Y | 5.2 | 9.8 | 12.98 - 11.03 | 11.02 - 9.52 | 9.51 - 8.81 | 8.80 - 7.87 | 7.86 - 7.14 | 7.13 - 6.50 | 6.49 - 4.53 | <= 4.52 | No | No | -- | -- |
| Screening Mammography Positive Predictive Value 2 (PPV2 - BiopsyRecommended) | ACRAD6 | Registry/QCDR | Outcome | Y | 9.3 | 27.7 | 19.89 - 21.61 | 21.62 - 25.57 | 25.58 - 27.77 | 27.78 - 29.66 | 29.67 - 31.59 | 31.60 - 36.47 | 36.48 - 39.57 | >= 39.58 | No | No | -- | -- |
| Screening Mammography Node Negativity Rate | ACRAD7 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Screening Mammography Minimal Cancer Rate | ACRAD8 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Median Dose Length Product for CT Head/Brain without contrast(single phase scan) | ACRAD9 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Median Size Specific Dose Estimate for CT Chest without contrast(single phase scan) | ACRAD10 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Median Dose Length Product for CT Chest without contrast (singlephase scan) | ACRAD11 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Median Size Specific Dose Estimate for CT Abdomen-Pelvis withContrast (single phase scan) | ACRAD12 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Median Dose Length Product for CT Abdomen-pelvis with contrast(single phase scan) | ACRAD13 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Participation in a National Dose Index Registry | ACRAD14 | Registry/QCDR | Process | Y | 1 | 99.5 | 99.59 - 99.68 | 99.69 - 99.84 | -- | 99.85 - 99.88 | -- | 99.89 - 99.98 | 99.99 - 99.99 | 100.00 | Yes | No | -- | -- |
| Report Turnaround Time: Radiography | ACRAD15 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Report Turnaround Time: Ultrasound (Excluding Breast US) | ACRAD16 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Report Turnaround Time: MRI | ACRAD17 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Report Turnaround Time: CT | ACRAD18 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Report Turnaround Time: PET | ACRAD19 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| CT IV Contrast Extravasation Rate (Low Osmolar Contrast Media) | ACRAD20 | Registry/QCDR | Outcome | Y | 0.1 | 0 | 0.07 - 0.01 | -- | -- | -- | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| Lung Cancer Screening Cancer Detection Rate (CDR) | ACRAD21 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Lung Cancer Screening Positive Predictive Value (PPV) | ACRAD22 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Lung Cancer Screening Abnormal Interpretation Rate | ACRAD23 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Hepatitis C Virus (HCV) - Sustained Virological Response | AGA1 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Coronary Artery Bypass Graft (CABG): Prolonged Intubation | AQI18 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| New Corneal Injury Not Diagnosed in the Postanesthesia Care Unit/Recovery Area after Anesthesia Care | AQI28 | Registry/QCDR | Outcome | Y | 0.2 | 99.9 | -- | -- | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Prevention of Post-Operative Vomiting (POV) - Combination Therapy (Pediatrics) | AQI29 | Registry/QCDR | Process | Y | 1.3 | 99.8 | -- | -- | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Composite Anesthesia Safety | AQI30 | Registry/QCDR | Outcome | Y | 0.8 | 99.7 | 99.70 - 99.80 | 99.81 - 99.87 | 99.88 - 99.97 | 99.98 - 99.99 | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Postanesthesia Care Unit (PACU) Re-intubation Rate | AQI31 | Registry/QCDR | Intermediate Out | Y | 9.5 | 1 | -- | -- | -- | -- | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| Composite Procedural Safety for Central Line Placement | AQI32 | Registry/QCDR | Intermediate Out | Y | 1 | 99.8 | -- | -- | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Composite Patient Experience | AQI33 | Registry/QCDR | Process | Y | 12.7 | 98 | -- | -- | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Perioperative Cardiac Arrest | AQI34 | Registry/QCDR | Outcome | Y | 0.2 | 0.1 | 0.10 - 0.01 | -- | -- | -- | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| Perioperative Mortality Rate | AQI35 | Registry/QCDR | Outcome | Y | 0.2 | 0.1 | 0.08 - 0.01 | -- | -- | -- | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| Assessment of Acute Postoperative Pain | AQI36 | Registry/QCDR | Intermediate Out | Y | 1.5 | 99.3 | 98.96 - 99.43 | 99.44 - 99.75 | 99.76 - 99.99 | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Surgical Safety Checklist ?Applicable Safety Checks Completed Before Induction of Anesthesia | AQI37 | Registry/QCDR | Process | Y | 0.6 | 99.9 | -- | -- | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Unplanned Transfer or Admission to Hospital | AQI40 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Coronary Artery Bypass Graft (CABG): Stroke | AQI41 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Coronary Artery Bypass Graft (CABG): Post-Operative Renal Failure | AQI42 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Rate of Post-operative stroke or death in asymptomatic patients undergoing Carotid Artery Stenting (CAS) | AQI43 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Rate of Post-operative stroke or death in asymptomatic patients undergoing Carotid Endarterectomy (CEA) | AQI44 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Rate of Endovascular aneurysm repair (EVAR) of small or moderate non-ruptured abdominal aortic aneurysms (AAA) who die while in the hospital | AQI45 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation | AQI46 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet | AQI47 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Prostate Cancer: Documentation of PSA, Gleason score and clinical stage for risk stratification | AQUA1 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Prostate Cancer: Documentation of extent of biopsy involvement in the MD note | AQUA2 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Cryptorchidism: Inappropriate use of scrotal/groin ultrasound on boys | AQUA3 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Hypogonadism: Testosterone lab ordered / reported within 6 months of starting testosterone replacement | AQUA4 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Benign Prostate Hyperplasia: Do not order creatinine lab for patients | AQUA5 | Registry/QCDR | Process | Y | 8.6 | 6 | 10.00 - 8.79 | 8.78 - 4.63 | 4.62 - 3.14 | 3.13 - 1.53 | 1.52 - 0.01 | -- | -- | 0.00 | Yes | No | -- | -- |
| Benign Prostate Hyperplasia: Do not order upper-tract imaging | AQUA6 | Registry/QCDR | Process | Y | 8.9 | 7 | 10.77 - 8.81 | 8.80 - 5.53 | 5.52 - 4.44 | 4.43 - 2.55 | 2.54 - 0.01 | -- | -- | 0.00 | Yes | No | -- | -- |
| Benign Prostate Hyperplasia: IPSS change 6 months after diagnosis | AQUA7 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Hospital re-admissions / complications within 30 days of TRUS Biopsy | AQUA8 | Registry/QCDR | Outcome | Y | 2.4 | 3.3 | 1.41 - 1.68 | 1.69 - 2.07 | 2.08 - 2.62 | 2.63 - 3.56 | 3.57 - 3.87 | 3.88 - 4.34 | 4.35 - 5.96 | >= 5.97 | No | No | -- | -- |
| Prostate Cancer: Use of active surveillance / watchful waiting for low-risk prostate cancer | AQUA9 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Surgeon assessment for hereditary cause of breast cancer | ASBS1 | Registry/QCDR | Process | Y | 4.6 | 98.7 | 99.34 - 99.63 | 99.64 - 99.99 | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Surgical Site Infection and Cellulitis After Breast and/or Axillary Surgery | ASBS2 | Registry/QCDR | Outcome | Y | 1.8 | 1.4 | 2.38 - 1.60 | 1.59 - 1.34 | 1.33 - 0.93 | 0.92 - 0.44 | 0.43 - 0.01 | -- | -- | 0.00 | Yes | No | -- | -- |
| Specimen orientation for partial mastectomy or excisional breast biopsy | ASBS3 | Registry/QCDR | Process | Y | 0.9 | 99.7 | -- | -- | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Unplanned 30 day re-operation after mastectomy | ASBS7 | Registry/QCDR | Outcome | Y | 1.5 | 99.1 | 97.62 - 98.52 | 98.53 - 99.99 | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Management of the axilla in breast cancer patients undergoing breast conserving surgery with a positive sentinel node biopsy | ASBS10 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Surgeon documentation of clinical stage of breast cancer | ASBS11 | Registry/QCDR | Process | Y | 12.2 | 96.1 | 98.54 - 99.36 | 99.37 - 99.99 | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Cardiac Stress Nuclear Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients | ASNC1 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Cardiac Stress Nuclear Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI) | ASNC2 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Cardiac Stress Nuclear Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients | ASNC3 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Utilization of standardized nomenclature and reporting for nuclear cardiology imaging studies | ASNC4 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| SPECT and PET MPI studies signed within two business days | ASNC12 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| SPECT-MPI studies meeting appropriate use criteria | ASNC13 | Registry/QCDR | Efficiency | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| SPECT-MPI study quality excellent or good | ASNC15 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| SPECT-MPI studies not Equivocal | ASNC17 | Registry/QCDR | Efficiency | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| SPECT-MPI studies performed without the use of thallium | ASNC20 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Train of Four Monitor Documented After Last Dose of Non-depolarizing Neuromuscular Blocker | ASPIRE2 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Administration of Neostigmine before Extubation for Cases with Nondepolarizing Neuromuscular Blockade | ASPIRE3 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Administration of insulin or glucose recheck for patients with hyperglycemia | ASPIRE4 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Avoiding excessively high tidal volumes during positive pressure ventilation | ASPIRE6 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Active warming for all patients at risk of intraoperative hypothermia | ASPIRE7 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Core temperature measurement for all general anesthetics | ASPIRE8 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Colloid use limited in cases with no indication | ASPIRE11 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Hemoglobin or hematrocrit measurement for patients receiving discretionary intraoperative red blood cell transfusions | ASPIRE12 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Transfusion goal of hematocrit less than 30 | ASPIRE13 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Avoiding intraoperative hypotension | ASPIRE16 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Avoiding gaps in systolic or mean arterial pressure measurement | ASPIRE17 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Avoiding myocardial Injury | ASPIRE18 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Avoiding acute kidney injury | ASPIRE19 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Avoiding medication overdose | ASPIRE22 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Use of wound surface culture technique in patients with chronic skin ulcers (overuse measure) | ASPS1 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Use of wet to dry dressings in patients with chronic skin ulcers (overuse measure) | ASPS2 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Use of compression system in patients with venous ulcers | ASPS3 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Offloading (pressure relief) of diabetic foot ulcer | ASPS4 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Breast Reconstruction: Return to OR | ASPS5 | Registry/QCDR | Intermediate Out | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Breast Reconstruction: Flap Loss | ASPS6 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Hand Sanitation Performed By My Provider | BIVARUS1 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Medication Reconciliation Performed At My Visit | BIVARUS2 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Practice Asked Me About Allergies | BIVARUS3 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Practice Explained Medications Before Giving Them | BIVARUS5 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Coordination Of Care Among Physicians and Nurses | BIVARUS7 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| I Was Told How To Arrange An Appointment For Follow-Up Care | BIVARUS9 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Overall Assessment of Safety | BIVARUS10 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| The Doctor Provided Follow-Up Care Instructions In A Way I Could Understand | BIVARUS11 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| I Was Involved in Developing My Care or Follow-Up Plan | BIVARUS12 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| My Pain Was Treated Effectively | BIVARUS13 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| My Doctor Listened To Me | BIVARUS16 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| My Doctor Made Me Feel Comfortable About Asking Questions | BIVARUS17 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| My Doctor Explained My Final Diagnosis | BIVARUS19 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| I Understood What the Physician Told Me | BIVARUS20 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| My Doctor Informed Me Of My Treatment Options | BIVARUS22 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| My Doctor Told Me How Long Things Would Take | BIVARUS23 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| My Doctor Did Not Seem Rushed While With Me | BIVARUS24 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| While In My Room, My Doctor Was Focused On Me/My Issues | BIVARUS25 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| How Likely Are You to Recommend This Physician to Your Family and Friends | BIVARUS26 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Adequate Off-loading of Diabetic Foot Ulcers at each visit | CDR1 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Diabetic Foot Ulcer (DFU) Healing or Closure | CDR2 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Diabetic Foot & Ankle Care: Comprehensive Diabetic Foot Examination | CDR4 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Adequate Compression at each visit for Patients with Venous Leg Ulcers (VLU) | CDR5 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Venous Leg Ulcer outcome measure: Healing or Closure | CDR6 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| 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) | CDR9 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Vascular Assessment of patients with chronic leg ulcers | CDR10 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Wound Bed Preparation Through Debridement of Necrotic or Non-viable Tissue | CDR11 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Wound Related Quality of Life | CDR12 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Door to Diagnostic Evaluation by a Provider ?All Emergency Department (ED) Patients | ECPR1 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Door to Diagnostic Evaluation by a Provider ?Adult Emergency Department (ED) Patients | ECPR2 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Door to Diagnostic Evaluation by a Provider ?Pediatric Emergency Department (ED) Patients | ECPR3 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Mean Time from Emergency Department (ED) Arrival to ED Departure for All Discharged ED Patients | ECPR4 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Mean Time from Emergency Department (ED) Arrival to ED Departure for Discharged Lower Acuity ED Patients | ECPR5 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Mean Time from Emergency Department (ED) Arrival to ED Departure for Discharged Higher Acuity ED Patients | ECPR6 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Three Day All Cause Return ED Visit Rate ?All Patients | ECPR11 | Registry/QCDR | Outcome | Y | 1 | 5 | 5.94 - 5.66 | 5.65 - 5.35 | 5.34 - 5.10 | 5.09 - 4.68 | 4.67 - 4.42 | 4.41 - 4.16 | 4.15 - 3.64 | <= 3.63 | No | No | -- | -- |
| Three Day All Cause Return ED Visit Rate ?Adults | ECPR12 | Registry/QCDR | Outcome | Y | 1 | 5.4 | 6.25 - 6.06 | 6.05 - 5.67 | 5.66 - 5.54 | 5.53 - 5.16 | 5.15 - 4.68 | 4.67 - 4.41 | 4.40 - 3.96 | <= 3.95 | No | No | -- | -- |
| Three Day All Cause Return ED Visit Rate ?Pediatrics | ECPR13 | Registry/QCDR | Outcome | Y | 1.4 | 2.3 | 3.30 - 3.00 | 2.99 - 2.68 | 2.67 - 2.31 | 2.30 - 1.80 | 1.79 - 1.55 | 1.54 - 1.05 | 1.04 - 0.49 | <= 0.48 | No | No | -- | -- |
| Initiation of the Initial Sepsis Bundle | ECPR24 | Registry/QCDR | Process | Y | 22.7 | 78.2 | 55.81 - 78.52 | 78.53 - 81.23 | 81.24 - 87.77 | 87.78 - 90.64 | 90.65 - 94.20 | 94.21 - 95.44 | 95.45 - 97.56 | >= 97.57 | No | No | -- | -- |
| Door to Diagnostic Evaluation by a Provider ?All Urgent Care Patients | ECPR29 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Door to Diagnostic Evaluation by a Provider ?Adult Urgent Care Patients | ECPR30 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Door to Diagnostic Evaluation by a Provider ?Pediatric Urgent Care Patients | ECPR31 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Mean Time from Urgent Care Clinic (UCC) Arrival to UCC Departure for All Discharged UCC Patients | ECPR32 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Mean Time from Urgent Care Clinic (UCC) Arrival to UCC Departure for Adult Discharged UCC Patients | ECPR33 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Mean Time from Urgent Care Clinic (UCC) Arrival to UCC Departure for Pediatric Discharged UCC Patients | ECPR34 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Mean Time from Emergency Department (ED) Arrival to ED Departure for All Admitted ED Patients | ECPR35 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Mean Time from Emergency Department (ED) Arrival to ED Departure for Admitted Adult ED Patients | ECPR36 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Three Day All Cause Return ED Visit Rate with Admission on Re-Visit | ECPR38 | Registry/QCDR | Outcome | Y | 0.4 | 1.5 | 1.92 - 1.79 | 1.78 - 1.62 | 1.61 - 1.49 | 1.48 - 1.34 | 1.33 - 1.26 | 1.25 - 1.18 | 1.17 - 0.95 | <= 0.94 | No | No | -- | -- |
| Avoid Head CT for Patients with Uncomplicated Syncope | ECPR39 | Registry/QCDR | Process | Y | 13 | 77.9 | 65.22 - 73.99 | 74.00 - 77.49 | 77.50 - 80.64 | 80.65 - 84.37 | 84.38 - 86.46 | 86.47 - 89.28 | 89.29 - 92.76 | >= 92.77 | No | No | -- | -- |
| Pain Management for Long Bone Fracture | ECPR40 | Registry/QCDR | Process | Y | 4.9 | 94.6 | 91.67 - 92.97 | 92.98 - 93.74 | 93.75 - 95.44 | 95.45 - 96.42 | 96.43 - 97.95 | 97.96 - 99.99 | -- | 100.00 | Yes | No | -- | -- |
| Coagulation Studies in Patients Presenting with Chest Pain with No Coagulopathy or Bleeding | ECPR41 | Registry/QCDR | Process | Y | 19.2 | 77.8 | 55.22 - 67.88 | 67.89 - 74.73 | 74.74 - 84.81 | 84.82 - 86.89 | 86.90 - 90.57 | 90.58 - 98.27 | 98.28 - 99.04 | >= 99.05 | No | No | -- | -- |
| Overall Anesthesia Safety | EPREOP1 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Overall Mortality | EPREOP2 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| PACU Intubation Rate | EPREOP3 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Short-term Pain Management/Maximum Pain Score | EPREOP4 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Procedural Safety for Central Venous or Arterial Catheterization | EPREOP5 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Surgical Safety Checklist/Timeout | EPREOP6 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Corneal Injury | EPREOP7 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Failed Airway | EPREOP8 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Prophylactic Antibiotic Administration | EPREOP9 | Registry/QCDR | Process | Y | 1.1 | 99.6 | 99.51 - 99.75 | 99.76 - 99.87 | 99.88 - 99.99 | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Intraoperative Fire | EPREOP10 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Case Delay | EPREOP11 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Anaphylaxis | EPREOP12 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Malignant Hyperthermia | EPREOP13 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Dental Injury | EPREOP14 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Unplanned admission to ICU | EPREOP15 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Unplanned admission to Hospital | EPREOP16 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| PONV Pediatric | EPREOP17 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Procedural Site Infection | EPREOP18 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Documentation of Current Medications in the Medical Record | EPREOP19 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Pain Assessment and Follow-Up | EPREOP20 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Tobacco Use: Screening and Cessation Intervention | EPREOP21 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Preoperative Fluid Intake for Elective Intra-Abdominal Procedures | EPREOP22 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Unplanned Readmission Within 30 Days of Principal Procedure | EPREOP23 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Overall Cardiac Arrest | EPREOP24 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Patient Experience | EPREOP25 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Adequacy of bowel preparation | GIQIC2 | Registry/QCDR | Process | Y | 4.7 | 95.9 | 93.74 - 95.55 | 95.56 - 96.79 | 96.80 - 97.55 | 97.56 - 98.12 | 98.13 - 98.64 | 98.65 - 99.02 | 99.03 - 99.37 | >= 99.38 | Yes | No | -- | -- |
| Photodocumentation of the cecum (also known as cecal intubation rate) ?All Colonoscopies | GIQIC3 | Registry/QCDR | Process | Y | 2.8 | 97.8 | 96.79 - 97.61 | 97.62 - 98.12 | 98.13 - 98.47 | 98.48 - 98.82 | 98.83 - 99.08 | 99.09 - 99.37 | 99.38 - 99.68 | >= 99.69 | Yes | No | -- | -- |
| Photodocumentation of the cecum (also known as cecal intubation rate) ?Screening Colonoscopies | GIQIC4 | Registry/QCDR | Process | Y | 2.7 | 98.4 | 97.62 - 98.27 | 98.28 - 98.72 | 98.73 - 99.04 | 99.05 - 99.36 | 99.37 - 99.60 | 99.61 - 99.77 | 99.78 - 99.99 | 100.00 | Yes | No | -- | -- |
| Incidence of perforation | GIQIC5 | Registry/QCDR | Outcome | Y | 0 | 0 | -- | -- | -- | -- | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| Appropriate follow-up interval for normal colonoscopy in average risk patients | GIQIC6 | Registry/QCDR | Process | Y | 12.1 | 89.4 | 84.56 - 88.63 | 88.64 - 90.71 | 90.72 - 92.97 | 92.98 - 94.38 | 94.39 - 95.70 | 95.71 - 97.21 | 97.22 - 98.73 | >= 98.74 | No | No | -- | -- |
| Age appropriate screening colonoscopy | GIQIC8 | Registry/QCDR | Outcome | Y | 0.3 | 0.1 | -- | -- | -- | -- | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| Documentation of history and physical rate - Colonoscopy | GIQIC9 | Registry/QCDR | Process | Y | 4.2 | 99 | 99.37 - 99.73 | 99.74 - 99.89 | 99.90 - 99.99 | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Appropriate management of anticoagulation in the peri-procedural period rate ?EGD | GIQIC10 | Registry/QCDR | Process | Y | 15.7 | 88.6 | 74.07 - 83.50 | 83.51 - 89.65 | 89.66 - 96.61 | 96.62 - 97.84 | 97.85 - 99.99 | -- | -- | 100.00 | Yes | No | -- | -- |
| Helicobacter pylori (H. pylori) status rate | GIQIC11 | Registry/QCDR | Process | Y | 10.8 | 91.4 | 82.51 - 85.95 | 85.96 - 91.37 | 91.38 - 96.29 | 96.30 - 99.99 | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Appropriate indication for colonoscopy | GIQIC12 | Registry/QCDR | Process | Y | 8.1 | 90.3 | 84.85 - 87.69 | 87.70 - 90.11 | 90.12 - 92.09 | 92.10 - 93.79 | 93.80 - 95.58 | 95.59 - 96.90 | 96.91 - 98.74 | >= 98.75 | No | No | -- | -- |
| Repeat screening colonoscopy recommended within one year due to inadequate bowel preparation | GIQIC14 | Registry/QCDR | Outcome | Y | 31.8 | 45.8 | 17.65 - 24.99 | 25.00 - 27.41 | 27.42 - 31.57 | 31.58 - 37.28 | 37.29 - 69.99 | 70.00 - 86.95 | 86.96 - 93.32 | >= 93.33 | No | No | -- | -- |
| Appropriate follow-up interval of 3 years recommended based on pathology findings from screening colonoscopy in average-risk patients | GIQIC15 | Registry/QCDR | Process | Y | 16.4 | 80 | 68.00 - 75.99 | 76.00 - 82.34 | 82.35 - 85.03 | 85.04 - 87.87 | 87.88 - 90.62 | 90.63 - 92.30 | 92.31 - 95.34 | >= 95.35 | No | No | -- | -- |
| Adenoma detection rate | GIQIC16 | Registry/QCDR | Intermediate Out | Y | 11.7 | 40.7 | 30.69 - 34.35 | 34.36 - 36.99 | 37.00 - 39.87 | 39.88 - 43.05 | 43.06 - 45.82 | 45.83 - 49.99 | 50.00 - 55.65 | >= 55.66 | No | No | -- | -- |
| 30 Day All Cause Re-Admission Rate for All Discharged Inpatients | HCPR6 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| 30 Day All Cause Re-Admission Rate Following Pneumonia Hospitalization | HCPR7 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| 30 Day All Cause Re-Admission Rate Following CHF Hospitalization | HCPR8 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| 30 Day All Cause Re-Admission Rate Following COPD Hospitalization | HCPR9 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Pain Brought Under Control within 2 Encounters | ICLOPS43 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Patients Treated With an Opioid Who Are Given a Bowel Regimen | ICLOPS44 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Palliative Care: Pain Screening | ICLOPS48 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Percentage of Palliative Care Patients With Documentation in the Clinical Record of a Discussion of Spiritual/Religious Concerns Or Documentation that the Patient/Caregiver Did Not Want to Discuss | ICLOPS53 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Corneal Graft Surgery - Postoperative Improvement in Visual Acuity of 20/40 or greater | IRIS1 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Glaucoma - Intraocular Pressure (IOP)Reduction | IRIS2 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Glaucoma - Visual Field Progression | IRIS3 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Glaucoma - Intraocular Pressure Reduction Following Laser Trabeculoplasty | IRIS4 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Surgery for Acquired Involutional Ptosis - Patients with an Improvement of Marginal Reflex Distance | IRIS5 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Acquired Involutional Entropion - Normalized Lid Position After Surgical Repair | IRIS6 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Amblyopia - Interocular Visual Acuity | IRIS7 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Surgical Esotropia: Postoperative Alignment | IRIS8 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Diabetic Retinopathy - Documentation of the Presence or Absence of Macular Edema and the Level of Severity of Retinopathy | IRIS9 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Exudative Age-Related Macular Degeneration - Loss of Visual Acuity | IRIS10 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Nonexudative Age-Related Macular Degeneration - Loss of Visual Acuity | IRIS11 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Age-Related Macular Degeneration: Disease Progression | IRIS12 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Diabetic Macular Edema: Loss of Visual Acuity | IRIS13 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Acute Anterior Uveitis: Post-treatment visual acuity | IRIS16 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Acute Anterior Uveitis: Post-treatment Grade 0 anterior chamber cells | IRIS17 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Chronic Anterior Uveitis: Post-treatment visual acuity | IRIS18 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Chronic Anterior Uveitis: Post-treatment Grade 0 anterior chamber cells | IRIS19 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Idiopathic Intracranial Hypertension: No worsening or improvement of mean deviation | IRIS20 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Ocular Myasthenia Gravis: Improvement of ocular deviation or absence of diplopia or functional improvement | IRIS21 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Giant Cell Arteritis: Absence of fellow eye involvement after corticosteroid treatment | IRIS22 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Procedures with statin and antiplatelet agents prescribed at discharge | M2S1 | Registry/QCDR | Process | Y | 13.7 | 75.4 | 66.13 - 67.64 | 67.65 - 69.04 | 69.05 - 75.12 | 75.13 - 78.78 | 78.79 - 83.32 | 83.33 - 87.65 | 87.66 - 93.74 | >= 93.75 | No | No | -- | -- |
| Amputation-free survival assessed at least 9 months following Infra Inguinal Bypass for intermittent claudication | M2S2 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Infrainguinal bypass for claudication patency assessed at least 9 months following surgery | M2S3 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Amputation-free survival assessed at least 9 months following Supra-Inguinal Bypass for claudication | M2S4 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Amputation-free survival assessed at least 9 months following Peripheral Vascular Intervention for intermittent claudication | M2S5 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Peripheral Vascular Intervention patency assessed at least 9 months following infrainguinal PVI for claudication | M2S6 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Ipsilateral stroke-free survival assessed at least 9 months following Carotid Artery Stenting for asymptomatic procedures | M2S7 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Ipsilateral stroke-free survival assessed at least 9 months following isolated CEA for asymptomatic procedures | M2S8 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Imaging-based maximum aortic diameter assessed at least 9 months following Thoracic and Complex EVAR procedures | M2S9 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Survival at least 9 months after elective repair of small thoracic aortic aneurysms | M2S10 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Imaging-based maximum aortic diameter assessed at least 9 months following Endovascular AAA Repair procedures | M2S11 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Survival at least 9 months after elective repair of small abdominal aortic aneurysms | M2S12 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Survival at least 9 months after elective open repair of small abdominal aortic aneurysms | M2S13 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Disease specific patient-reported outcome surveys for Varicose Vein procedures | M2S14 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Medical Complications | MBS1 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Surgical Site Complications | MBS2 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Serious Complications | MBS3 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| MBSC Venous Thromboembolism prophylaxis adherence rates for Perioperative Care | MBS4 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| MBSC Venous Thromboembolism prophylaxis adherence rates for Postoperative Care | MBS5 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| MBSC Venous Thromboembolism prophylaxis adherence rates for Post-discharge Care | MBS6 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Extended Length of Stay (LOS) | MBS7 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Unplanned Emergency Room (ER) visits | MBS8 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Unplanned Hospital Readmission within 30 Days of Principal Procedure | MBS9 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Risk standardized rate of patients who experienced a postoperative complication within 30 days following a primary Laparoscopic Roux-en-Y Gastric Bypass (LRTGB) or Laparoscopic Sleeve Gastrectomy (LSG) operation. | MBSAQIP1 | Registry/QCDR | Outcome | Y | 2.9 | 4.8 | 7.03 - 5.54 | 5.53 - 4.53 | 4.52 - 4.02 | 4.01 - 3.58 | 3.57 - 3.34 | 3.33 - 2.09 | 2.08 - 1.80 | <= 1.79 | Yes | No | -- | -- |
| Risk standardized rate of patients who experienced an unplanned readmission within 30 days following primary LRYGB or LSG operation.Risk standardized rate of patients who experienced a reoperation within 30 days following primary a LRYGB or LSG operation. | MBSAQIP2 | Registry/QCDR | Outcome | Y | 2.1 | 3 | 4.17 - 3.86 | 3.85 - 3.34 | 3.33 - 2.35 | 2.34 - 2.11 | 2.10 - 1.93 | 1.92 - 1.19 | 1.18 - 0.01 | 0.00 | No | No | -- | -- |
| Risk standardized rate of patients who experienced a reoperation within 30 days following a primary LRYGB or LSG operation. | MBSAQIP3 | Registry/QCDR | Outcome | Y | 0.7 | 0.5 | 1.18 - 0.71 | 0.70 - 0.01 | -- | -- | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| Risk standardized rate of patients who experienced an anastomotic/staple line leak within 30 days following primary LRYGB or LSG operation. | MBSAQIP4 | Registry/QCDR | Outcome | Y | 0.6 | 0.2 | 0.31 - 0.01 | -- | -- | -- | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| Risk standardized rate of patients who experienced a bleeding/hemorrhage event requiring transfusion, intervention/operation, or readmission within 30 days following primary LRYGB or LGS operation | MBSAQIP5 | Registry/QCDR | Outcome | Y | 0.8 | 0.5 | 1.19 - 0.57 | 0.56 - 0.01 | -- | -- | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| 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 primary LRYGB or LSG operation | MBSAQIP6 | Registry/QCDR | Outcome | Y | 1 | 0.5 | 1.19 - 0.01 | -- | -- | -- | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| Risk standardized rate of patients who experienced postoperative nausea, vomiting or fluid/electrolyte/nutritional depletion within 30 days following primary LRYGB or LSG operation. | MBSAQIP7 | Registry/QCDR | Outcome | Y | 1.4 | 1.3 | 2.04 - 1.86 | 1.85 - 1.85 | 1.84 - 1.49 | 1.48 - 0.01 | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| Risk standardized rate of patients who experienced extended length of stay (> 7 days) following primary LRYGB or LSG operation | MBSAQIP8 | Registry/QCDR | Outcome | Y | 0.9 | 0.3 | 0.31 - 0.01 | -- | -- | -- | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| Percentage of patients who had complete 30 day follow-up following any metabolic and bariatric procedure. | MBSAQIP9 | Registry/QCDR | Process | Y | 3.3 | 97.7 | 95.45 - 97.72 | 97.73 - 98.52 | 98.53 - 98.80 | 98.81 - 99.66 | 99.67 - 99.99 | -- | -- | 100.00 | Yes | No | -- | -- |
| Perioperative Cardiac Arrest Rate | MIRAMED1 | Registry/QCDR | Outcome | Y | 0 | 100 | -- | -- | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| PACU Intubation Rate | MIRAMED2 | Registry/QCDR | Outcome | Y | 0.5 | 99.8 | 99.80 - 99.89 | 99.90 - 99.99 | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Dental Injury | MIRAMED3 | Registry/QCDR | Outcome | Y | 0.5 | 99.8 | 99.75 - 99.99 | -- | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Perioperative Mortality Rate | MIRAMED4 | Registry/QCDR | Outcome | Y | 0 | 100 | -- | -- | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Adult PACU Pain Management | MIRAMED5 | Registry/QCDR | Outcome | Y | 0.8 | 99.6 | 99.40 - 99.59 | 99.60 - 99.79 | 99.80 - 99.89 | 99.90 - 99.99 | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Anaphylaxis During Anesthesia Care | MIRAMED6 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Corneal Abrasion | MIRAMED7 | Registry/QCDR | Outcome | Y | 0.4 | 0.2 | 0.40 - 0.21 | 0.20 - 0.11 | 0.10 - 0.01 | -- | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| Case Cancellation Rate | MIRAMED8 | Registry/QCDR | Process | Y | 0.5 | 99.7 | 99.70 - 99.79 | 99.80 - 99.89 | 99.90 - 99.99 | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Case Delay Rate | MIRAMED9 | Registry/QCDR | Process | Y | 2.7 | 97.8 | 99.80 - 99.71 | 99.70 - 99.41 | 99.40 - 98.51 | 98.50 - 98.41 | 98.40 - 97.11 | 97.10 - 96.21 | 96.20 - 94.31 | <= 94.30 | No | No | -- | -- |
| Unplanned Use of Difficult Airway Equipment and/or Failed Airway | MIRAMED10 | Registry/QCDR | Process | Y | 0.8 | 99.5 | 99.10 - 99.49 | 99.50 - 99.69 | 99.70 - 99.89 | 99.90 - 99.99 | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Appropriate Use of Advanced Imaging by Ordering Provider | MOA2 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Adherence to Controlled Substance Agreement/Opiate Agreement with Corrective Actions for Violations | MOA7 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Efficacy of Manipulative Medicine with Treatment Adjustment | MOA12 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Report Turnaround Time: Radiography | MSN3 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Report Turnaround Time: Ultrasound (Excluding Breast US) | MSN4 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Report Turnaround Time: MRI | MSN5 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Report Turnaround Time: CT | MSN6 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Report Turnaround Time: PET | MSN7 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Prostate Biopsy: Compliance with AUA best practices for antibiotic prophylaxis for transrectal ultrasound-guided (TRUS) biopsy | MUSIC1 | Registry/QCDR | Process | Y | 2.6 | 98.9 | 98.57 - 98.95 | 98.96 - 99.99 | -- | -- | -- | -- | -- | 100.00 | Yes | No | -- | -- |
| Unplanned Hospital Admission within 30 Days of TRUS Biopsy: | MUSIC2 | Registry/QCDR | Outcome | Y | 0.8 | 0.4 | 0.72 - 0.01 | -- | -- | -- | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| Prostate Cancer: Avoidance of Overuse of CT Scan for Staging Low Risk Prostate Cancer Patients: | MUSIC3 | Registry/QCDR | Process | Y | 9.5 | 55.7 | 47.51 - 50.40 | 50.41 - 52.25 | 52.26 - 55.92 | 55.93 - 56.83 | 56.84 - 60.46 | 60.47 - 62.28 | 62.29 - 68.41 | >= 68.42 | No | No | -- | -- |
| Prostate Cancer: Proportion of patients with low-risk prostate cancer receiving active surveillance | MUSIC4 | Registry/QCDR | Outcome | Y | 10.2 | 18 | 9.52 - 11.85 | 11.86 - 13.72 | 13.73 - 15.89 | 15.90 - 17.85 | 17.86 - 21.56 | 21.57 - 27.37 | 27.38 - 33.32 | >= 33.33 | No | No | -- | -- |
| Prostate Cancer: Percentage of prostate cancer cases with a length of stay > 2 days | MUSIC5 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Unplanned Hospital Readmission within 30 Days of Radical Prostatectomy: | MUSIC6 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Prostate Biopsy: Proportion of patients undergoing initial prostate biopsy in the registry found to have prostate cancer | MUSIC7 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Prostate Biopsy: Proportion of patients undergoing a prostate biopsy with a PSA < 4 | MUSIC8 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| 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 | MUSIC9 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Adequacy of Bowel Preparation | NHCR1 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Successful Cecal Intubation | NHCR2 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Incidence of perforation | NHCR3 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Repeat colonoscopy recommended due to poor bowel preparation | NHCR4 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Repeat colonoscopy recommended due to piecemeal resection | NHCR5 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Age inappropriate screening colonoscopy | NHCR6 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Documentation of family history | NHCR7 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Documentation of Indication for exam | NHCR8 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Patient Experience: Did the Patient Receive Adequate Instructions | NHQI24 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Perioperative Cardiac Arrest | NHQI27 | Registry/QCDR | Outcome | Y | 0 | 0 | 0.04 - 0.03 | -- | 0.02 - 0.02 | -- | -- | 0.01 - 0.01 | -- | 0.00 | No | No | -- | -- |
| Perioperative Mortality Rate | NHQI28 | Registry/QCDR | Outcome | Y | 0 | 0 | 0.03 - 0.03 | -- | 0.02 - 0.02 | -- | 0.01 - 0.01 | -- | -- | 0.00 | Yes | No | -- | -- |
| Critical Result: Pulmonary Embolism | NJIISMD1 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Critical Result: ICH | NJIISMD2 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Critical Result: Aortic Dissection | NJIISMD3 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Critical test: OR Foreign Body | NJIISMD4 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Critical test: Stroke | NJIISMD5 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Critical test: Intracranial Hemorrhage | NJIISMD6 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Critical test: Aortic Dissection | NJIISMD7 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Critical Result: Occlusive intracranial stroke | NJIISMD8 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Critical Result: Placental abruption | NJIISMD9 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Critical Result: Ruptured ectopic pregnancy | NJIISMD10 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Critical Result: New DVT | NJIISMD11 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Critical Result: Eptopic Pregnancy | NJIISMD12 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Critical Test Protocol | NJIISMD13 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Critical Result Protocol | NJIISMD14 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Functional Outcome Assessment for Spine Intervention | NPA3 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Quality-of-Life Assessment for Spine Intervention | NPA4 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Patient Satisfaction with Spine Care | NPA5 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Spine-related procedure site infection | NPA6 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Complication Following Spine-Related Procedure | NPA7 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Hospital Mortality following Spine Procedure | NPA8 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Unplanned Reoperation Following Spine Procedure Within the 30 Day Post-Operative Period | NPA10 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Unplanned Readmission Following Spine Procedure Within the 30 Day Post-Operative Period | NPA11 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Participation in a Systematic National Database for Spine Care Interventions | NPA21 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Back Pain: Mental Health Assessment | OBERD1 | Registry/QCDR | Process | Y | 13.1 | 71.4 | 67.27 - 69.67 | 69.68 - 70.84 | 70.85 - 74.03 | 74.04 - 75.42 | 75.43 - 77.77 | 77.78 - 79.21 | 79.22 - 80.99 | >= 81.00 | No | No | -- | -- |
| Back Pain: Patient Reassessment | OBERD2 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Pain Assessment and Follow-Up | OBERD4 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Back Pain: Surgical Timing | OBERD5 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Orthopedic Pain: Mental Health Assessment | OBERD6 | Registry/QCDR | Process | Y | 14.1 | 81.5 | 70.64 - 76.44 | 76.45 - 80.98 | 80.99 - 83.57 | 83.58 - 87.49 | 87.50 - 90.57 | 90.58 - 95.13 | 95.14 - 96.67 | >= 96.68 | No | No | -- | -- |
| Orthopedic Pain: Patient Reassessment | OBERD7 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Orthopedic Pain: Assessment and follow-up | OBERD9 | Registry/QCDR | Process | Y | 11.1 | 67.8 | 58.65 - 66.18 | 66.19 - 69.65 | 69.66 - 70.74 | 70.75 - 72.14 | 72.15 - 74.18 | 74.19 - 75.49 | 75.50 - 77.03 | >= 77.04 | No | No | -- | -- |
| Quality of Life (VR-12 or Promis Global 10) Monitoring | OBERD10 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Quality of Life (VR-12 or Promis Global 10) Outcomes | OBERD11 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| CG-CAHPS Adult Visit Composite Tracking | OBERD12 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Orthopedic Functional and Pain Level Outcomes | OBERD13 | Registry/QCDR | Outcome | Y | 27.8 | 62.4 | 86.11 - 79.89 | 79.88 - 74.60 | 74.59 - 70.13 | 70.12 - 61.40 | 61.39 - 49.51 | 49.50 - 39.93 | 39.92 - 18.43 | <= 18.42 | No | No | -- | -- |
| Orthopedic 3-Month Surgery Follow-up | OBERD14 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Orthopedic 3-Month Surgery Outcome | OBERD15 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| CG-CAHPS Patient Rating | OBERD17 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Orthopedic Surgery 3-Month QoL Changes (VR-6D) | OBERD19 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| 30 day Readmission for Acute Myocardial Infarction | PINC1 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| 30 day Readmission for Heart Failure | PINC2 | Registry/QCDR | Outcome | Y | 6.1 | 14.6 | 18.18 - 16.68 | 16.67 - 16.23 | 16.22 - 14.72 | 14.71 - 13.80 | 13.79 - 12.21 | 12.20 - 10.35 | 10.34 - 6.68 | <= 6.67 | No | No | -- | -- |
| 30 day Readmission for Pneumonia | PINC3 | Registry/QCDR | Outcome | Y | 6.9 | 13.8 | 19.23 - 15.95 | 15.94 - 15.01 | 15.00 - 12.89 | 12.88 - 11.12 | 11.11 - 9.77 | 9.76 - 8.34 | 8.33 - 5.57 | <= 5.56 | No | No | -- | -- |
| 30 day Mortality for Acute Myocardial Infarction | PINC4 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| 30 day Mortality for Heart Failure | PINC5 | Registry/QCDR | Outcome | Y | 3.2 | 2.9 | 4.76 - 3.61 | 3.60 - 3.34 | 3.33 - 2.57 | 2.56 - 1.62 | 1.61 - 0.01 | -- | -- | 0.00 | Yes | No | -- | -- |
| 30 day Mortality for Pneumonia | PINC6 | Registry/QCDR | Outcome | Y | 7.1 | 9.7 | 13.04 - 11.12 | 11.11 - 9.63 | 9.62 - 8.78 | 8.77 - 7.51 | 7.50 - 5.17 | 5.16 - 4.56 | 4.55 - 3.34 | <= 3.33 | Yes | No | -- | -- |
| Venous Thromboembolism (VTE) Prophylaxis | PINC7 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Thrombolytic Therapy | PINC21 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Discharged on Statin Medication | PINC22 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Stroke Education | PINC23 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| VTE Warfarin Therapy Discharge Instructions | PINC27 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Tobacco Use Treatment Provided or Offered | PINC28 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Median Time from ED Arrival to ED Departure for Admitted ED Patients | PINC29 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Admit Decision Time to ED Departure Time for Admitted Patients | PINC30 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Median Time from ED Arrival to ED Departure for Discharged ED Patients | PINC31 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Door to Diagnostic Evaluation by a Qualified Medical Professional | PINC32 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Risk-Adjusted Average Length of Inpatient Hospital Stay for Acute Myocardial Infarction (AMI) | PINC33 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Risk-Adjusted Average Length of Inpatient Hospital Stay for Heart Failure (HF) | PINC34 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Risk-Adjusted Average Length of Inpatient Hospital Stay for Pneumonia (PN) | PINC35 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Prevention of Post-Operative Nausea and Vomiting (PONV) - Combination Therapy (Pediatrics) | PINC44 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Post Anesthesia Care Unit (PACU) Re-intubation Rate | PINC45 | Registry/QCDR | Intermediate Out | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Immediate Perioperative Cardiac Arrest | PINC46 | Registry/QCDR | Intermediate Out | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Immediate Perioperative Mortality Rate | PINC47 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Composite Anesthesia Safety | PINC48 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Short-term Pain Management | PINC49 | Registry/QCDR | Intermediate Out | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Diabetes Mellitus (DM): Hemoglobin A1c Control (< 8%) | PPRNET1 | Registry/QCDR | Outcome | Y | 11.8 | 68.2 | 62.86 - 65.41 | 65.42 - 68.17 | 68.18 - 70.02 | 70.03 - 72.21 | 72.22 - 73.54 | 73.55 - 76.06 | 76.07 - 77.13 | >= 77.14 | Yes | No | -- | -- |
| Diabetes Mellitus (DM): Nephropathy Assessment | PPRNET2 | Registry/QCDR | Process | Y | 12.6 | 83.1 | 70.12 - 78.30 | 78.31 - 82.11 | 82.12 - 88.45 | 88.46 - 91.58 | 91.59 - 91.90 | 91.91 - 93.32 | 93.33 - 95.44 | >= 95.45 | No | No | -- | -- |
| Hypertension (HTN): Appropriate Diagnosis | PPRNET4 | Registry/QCDR | Process | Y | 7.3 | 87.9 | 83.45 - 84.24 | 84.25 - 85.86 | 85.87 - 87.49 | 87.50 - 91.41 | 91.42 - 92.16 | 92.17 - 94.29 | 94.30 - 97.52 | >= 97.53 | No | No | -- | -- |
| Hypertension (HTN): Controlling Blood Pressure | PPRNET5 | Registry/QCDR | Outcome | Y | 9.4 | 66.5 | 58.33 - 60.40 | 60.41 - 64.27 | 64.28 - 65.44 | 65.45 - 69.23 | 69.24 - 71.73 | 71.74 - 73.96 | 73.97 - 79.73 | >= 79.74 | No | No | -- | -- |
| Concordance with ACC/AHA Cholesterol Guidelines for ASCVD Risk Reduction | PPRNET6 | Registry/QCDR | Process | Y | 11.2 | 34.4 | 24.62 - 25.87 | 25.88 - 27.98 | 27.99 - 30.37 | 30.38 - 36.94 | 36.95 - 40.70 | 40.71 - 46.66 | 46.67 - 49.99 | >= 50.00 | No | No | -- | -- |
| Antiplatelet Medication for High Risk Patients | PPRNET8 | Registry/QCDR | Process | Y | 19.2 | 49.3 | 27.54 - 34.44 | 34.45 - 48.69 | 48.70 - 52.69 | 52.70 - 58.35 | 58.36 - 62.68 | 62.69 - 68.37 | 68.38 - 72.62 | >= 72.63 | No | No | -- | -- |
| Antithrombotic Medication for Patients with Atrial Fibrillation | PPRNET9 | Registry/QCDR | Process | Y | 12.2 | 80.5 | 70.41 - 72.96 | 72.97 - 73.76 | 73.77 - 81.98 | 81.99 - 87.87 | 87.88 - 89.12 | 89.13 - 90.31 | 90.32 - 94.91 | >= 94.92 | No | No | -- | -- |
| Heart Failure (HF): ACEI or ARB Therapy | PPRNET10 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Heart Failure (HF): Beta-Blocker Therapy | PPRNET11 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Screening for Abdominal Aortic Aneurysm | PPRNET12 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Chronic Kidney Disease (CKD): eGFR Monitoring | PPRNET13 | Registry/QCDR | Process | Y | 15.5 | 71.9 | 64.27 - 66.85 | 66.86 - 70.65 | 70.66 - 73.32 | 73.33 - 77.17 | 77.18 - 81.20 | 81.21 - 84.50 | 84.51 - 89.99 | >= 90.00 | No | No | -- | -- |
| Chronic Kidney Disease (CKD): Hemoglobin Monitoring | PPRNET14 | Registry/QCDR | Process | Y | 15.9 | 80.9 | 62.26 - 77.26 | 77.27 - 79.08 | 79.09 - 86.62 | 86.63 - 89.65 | 89.66 - 90.47 | 90.48 - 93.47 | 93.48 - 96.14 | >= 96.15 | No | No | -- | -- |
| Osteoporosis Screening for Women | PPRNET15 | Registry/QCDR | Process | Y | 24.9 | 56.9 | 37.14 - 44.59 | 44.60 - 51.03 | 51.04 - 56.00 | 56.01 - 66.38 | 66.39 - 79.30 | 79.31 - 82.71 | 82.72 - 84.47 | >= 84.48 | No | No | -- | -- |
| Cervical Cancer Screening | PPRNET16 | Registry/QCDR | Process | Y | 21.5 | 39.9 | 25.15 - 25.55 | 25.56 - 30.50 | 30.51 - 32.45 | 32.46 - 40.23 | 40.24 - 57.13 | 57.14 - 58.24 | 58.25 - 69.56 | >= 69.57 | No | No | -- | -- |
| Breast Cancer Screening | PPRNET17 | Registry/QCDR | Process | Y | 31.9 | 49.2 | 5.37 - 15.20 | 15.21 - 52.75 | 52.76 - 64.43 | 64.44 - 69.99 | 70.00 - 74.13 | 74.14 - 76.66 | 76.67 - 77.04 | >= 77.05 | No | No | -- | -- |
| Colorectal Cancer screening | PPRNET18 | Registry/QCDR | Process | Y | 17.4 | 60.9 | 46.82 - 51.65 | 51.66 - 56.97 | 56.98 - 62.00 | 62.01 - 67.09 | 67.10 - 70.59 | 70.60 - 77.08 | 77.09 - 80.94 | >= 80.95 | No | No | -- | -- |
| Pneumococcal Vaccination in Elderly | PPRNET19 | Registry/QCDR | Process | Y | 17.9 | 78.5 | 66.89 - 73.85 | 73.86 - 81.52 | 81.53 - 83.36 | 83.37 - 86.34 | 86.35 - 88.92 | 88.93 - 90.80 | 90.81 - 93.94 | >= 93.95 | No | No | -- | -- |
| Zoster (Shingles) Vaccination | PPRNET20 | Registry/QCDR | Process | Y | 24.1 | 52.8 | 26.33 - 38.46 | 38.47 - 52.22 | 52.23 - 55.90 | 55.91 - 59.67 | 59.68 - 71.08 | 71.09 - 74.94 | 74.95 - 81.66 | >= 81.67 | No | No | -- | -- |
| Depression Screening | PPRNET21 | Registry/QCDR | Process | Y | 37 | 48.5 | 7.69 - 10.91 | 10.92 - 23.94 | 23.95 - 45.53 | 45.54 - 79.11 | 79.12 - 84.87 | 84.88 - 88.41 | 88.42 - 91.39 | >= 91.40 | No | No | -- | -- |
| Alcohol Misuse Screening | PPRNET22 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Tobacco Use: Screening and Cessation Intervention | PPRNET23 | Registry/QCDR | Process | Y | 17.9 | 86.2 | 82.06 - 86.04 | 86.05 - 89.46 | 89.47 - 92.17 | 92.18 - 93.87 | 93.88 - 95.07 | 95.08 - 97.21 | 97.22 - 99.31 | >= 99.32 | No | No | -- | -- |
| Appropriate Treatment for Adults with Upper Respiratory Infection | PPRNET24 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Appropriate Antibiotic Use | PPRNET25 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Use of High-Risk Medications in the Elderly | PPRNET26 | Registry/QCDR | Process | Y | 5 | 85.7 | 81.64 - 82.97 | 82.98 - 84.78 | 84.79 - 85.36 | 85.37 - 86.29 | 86.30 - 88.07 | 88.08 - 90.08 | 90.09 - 93.42 | >= 93.43 | No | No | -- | -- |
| Use of Benzodiazepines in the Elderly | PPRNET27 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| NSAID or Cox 2 Inhibitor Use in Patients with Heart Failure (HF) or Chronic Kidney Disease (CKD) | PPRNET28 | Registry/QCDR | Process | Y | 5.2 | 85.6 | 80.89 - 83.26 | 83.27 - 85.20 | 85.21 - 85.70 | 85.71 - 86.44 | 86.45 - 87.98 | 87.99 - 89.31 | 89.32 - 94.23 | >= 94.24 | No | No | -- | -- |
| Monitoring Serum Potassium | PPRNET29 | Registry/QCDR | Process | Y | 15.7 | 84.2 | 80.47 - 81.95 | 81.96 - 83.76 | 83.77 - 87.74 | 87.75 - 90.46 | 90.47 - 92.78 | 92.79 - 94.58 | 94.59 - 97.21 | >= 97.22 | No | No | -- | -- |
| Treatment of Hypokalemia | PPRNET30 | Registry/QCDR | Outcome | Y | 3.1 | 96.6 | 94.78 - 96.66 | 96.67 - 97.06 | 97.07 - 97.51 | 97.52 - 98.23 | 98.24 - 98.51 | 98.52 - 98.73 | 98.74 - 99.10 | >= 99.11 | Yes | No | -- | -- |
| Screening for Type 2 Diabetes | PPRNET31 | Registry/QCDR | Process | Y | 10.4 | 87.7 | 81.19 - 84.51 | 84.52 - 87.46 | 87.47 - 90.78 | 90.79 - 92.76 | 92.77 - 93.62 | 93.63 - 95.35 | 95.36 - 98.07 | >= 98.08 | No | No | -- | -- |
| Central Venous Line: ultrasound used for placement | QUANTUM31 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Procedural Safety for Central Line Placement | QUANTUM32 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Dental Damage/Loss | QUANTUM34 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Aspiration of Gastric Contents | QUANTUM37 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Prevention of Post Operative Vomiting with an appropriate medical regimen guided by risk assessment in patients aged 3 to 18 years of age | QUANTUM39 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Surgical Case Cancellation | QUANTUM41 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Unplanned Hospital Admission | QUANTUM42 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Difficult Intubation due to unrecognized difficult airway | QUANTUM43 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Medication Error by Anesthesia Care Team | QUANTUM47 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Anaphylaxis | QUANTUM48 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Immediate Perioperative Cardiac Arrest | QUANTUM49 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Unplanned ICU Admission | QUANTUM51 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Change in Functional Outcome | SPINEIQ1 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Change in Pain Intensity | SPINEIQ2 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Repeated X-Ray Imaging | SPINEIQ3 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Patient Satisfaction Assessment | SPINEIQ4 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Prolonged Length of Stay following CABG | STS1 | Registry/QCDR | Outcome | Y | 4.2 | 5.3 | 7.94 - 6.34 | 6.33 - 5.27 | 5.26 - 4.40 | 4.39 - 3.58 | 3.57 - 2.74 | 2.73 - 2.01 | 2.00 - 0.94 | <= 0.93 | No | No | -- | -- |
| Short Length of Stay following CABG | STS2 | Registry/QCDR | Outcome | Y | 16.4 | 41.2 | 25.93 - 31.02 | 31.03 - 36.91 | 36.92 - 42.10 | 42.11 - 47.61 | 47.62 - 49.99 | 50.00 - 55.14 | 55.15 - 61.69 | >= 61.70 | No | No | -- | -- |
| Prolonged Length of Stay following CABG and Valve Surgery | STS3 | Registry/QCDR | Outcome | Y | 6.7 | 11.1 | 15.38 - 14.30 | 14.29 - 12.51 | 12.50 - 10.72 | 10.71 - 8.21 | 8.20 - 6.68 | 6.67 - 4.77 | 4.76 - 3.46 | <= 3.45 | No | No | -- | -- |
| Short Length of Stay following CABG and Valve Surgery | STS4 | Registry/QCDR | Outcome | Y | 14.1 | 22.7 | 8.51 - 9.99 | 10.00 - 18.45 | 18.46 - 22.60 | 22.61 - 25.39 | 25.40 - 31.81 | 31.82 - 36.35 | 36.36 - 43.99 | >= 44.00 | No | No | -- | -- |
| Prolonged Length of Stay following Valve Surgery | STS5 | Registry/QCDR | Outcome | Y | 4.7 | 5.5 | 9.52 - 7.33 | 7.32 - 5.57 | 5.56 - 4.77 | 4.76 - 4.01 | 4.00 - 2.64 | 2.63 - 0.01 | -- | 0.00 | No | No | -- | -- |
| Short Length of Stay following Valve Surgery | STS6 | Registry/QCDR | Outcome | Y | 16.1 | 37.7 | 22.73 - 28.56 | 28.57 - 34.77 | 34.78 - 38.19 | 38.20 - 41.85 | 41.86 - 45.44 | 45.45 - 51.60 | 51.61 - 61.10 | >= 61.11 | No | No | -- | -- |
| Patient Centered Surgical Risk Assessment and Communication using the STS Risk Calculator | STS7 | Registry/QCDR | Process | Y | 38.2 | 47.8 | 4.46 - 11.69 | 11.70 - 23.42 | 23.43 - 43.58 | 43.59 - 69.90 | 69.91 - 82.75 | 82.76 - 89.18 | 89.19 - 96.68 | >= 96.69 | No | No | -- | -- |
| Perioperative Aspiration Pneumonia rate | THPSO1 | Registry/QCDR | Outcome | Y | 0 | 0 | 0.05 - 0.05 | 0.04 - 0.03 | 0.02 - 0.02 | -- | 0.01 - 0.01 | -- | -- | 0.00 | Yes | No | -- | -- |
| Post-dural puncture headache rate | THPSO2 | Registry/QCDR | Outcome | Y | 0.1 | 0.1 | 0.12 - 0.07 | 0.06 - 0.01 | -- | -- | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| Perioperative Peripheral Nerve Injury rate | THPSO3 | Registry/QCDR | Outcome | Y | 0 | 0 | 0.02 - 0.02 | -- | 0.01 - 0.01 | -- | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| Pneumothorax rate as a complication of central line placement | THPSO4 | Registry/QCDR | Outcome | N | 0 | 0 | -- | -- | -- | -- | -- | -- | -- | 0.00 | -- | No | -- | -- |
| Ultrasound guidance for central line placement | THPSO5 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Perioperative Myocardial Infarction rate in low risk patients | THPSO6 | Registry/QCDR | Outcome | Y | 0.1 | 0 | 0.02 - 0.02 | 0.01 - 0.01 | -- | -- | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| Perioperative Myocardial Infarction rate in high risk patients | THPSO7 | Registry/QCDR | Outcome | Y | 0.1 | 0.1 | 0.05 - 0.03 | 0.02 - 0.01 | -- | -- | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| New perioperative central neurologic deficit | THPSO8 | Registry/QCDR | Outcome | Y | 0 | 0 | 0.01 - 0.01 | -- | -- | -- | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| Postoperative nausea and vomiting rate ?Adults | THPSO9 | Registry/QCDR | Outcome | Y | 0.4 | 0.2 | 0.19 - 0.12 | 0.11 - 0.06 | 0.05 - 0.05 | 0.04 - 0.02 | 0.01 - 0.01 | -- | -- | 0.00 | Yes | No | -- | -- |
| Postoperative nausea and vomiting rate ?Pediatrics | THPSO10 | Registry/QCDR | Outcome | Y | 0.1 | 0.1 | 0.19 - 0.01 | -- | -- | -- | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| Post-obstructive Pulmonary Edema rate following endo-tracheal intubation | THPSO11 | Registry/QCDR | Outcome | Y | 0 | 0 | 0.03 - 0.03 | 0.02 - 0.02 | 0.01 - 0.01 | -- | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| Respiratory Arrest in PACU rate | THPSO12 | Registry/QCDR | Outcome | Y | 0.5 | 0.1 | 0.03 - 0.02 | -- | 0.01 - 0.01 | -- | -- | -- | -- | 0.00 | Yes | No | -- | -- |
| Dental Injury Rate following airway management | THPSO13 | Registry/QCDR | Outcome | Y | 0.3 | 0.1 | 0.05 - 0.05 | 0.04 - 0.04 | -- | 0.03 - 0.03 | -- | 0.02 - 0.01 | -- | 0.00 | Yes | No | -- | -- |
| Patient Experience: Post anesthesia follow up | THPSO14 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Patient Vital Sign Assessment Prior to HBOT | USWR13 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Blood glucose check prior to hyperbaric oxygen therapy (HBOT) treatment | USWR14 | Registry/QCDR | Process | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Healing or Closure of Wagner Grade 3, 4 or 5 Diabetic Foot Ulcers (DFUs) Treated with HBOT | USWR15 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |
| Complications or Side Effects among patients undergoing Treatment with HBOT | USWR18 | Registry/QCDR | Outcome | N | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | No | -- | -- |