Quality Measures MIPS CV Specific

Transcription

1 Quality Measures MIPS CV Specific MEASURE NAME Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy CAHPS for MIPS Clinician/Group Survey Cardiac Rehabilitation Patient Referral from an Outpatient Setting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI) MEASURE TYPE HIGH PRIORITY MEASURE DATA SUBMISSION METHOD PRIMARY MEASURE STEWARD Process No Claims, American College of Patient Engagement Experience Yes CSV Agency for Healthcare Research & Quality Process Yes American College of Foundation Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients Care Plan Process Yes Claims, Closing the Referral Loop: Receipt of Specialist Report Controlling High Blood Pressure (CABG): Deep Sternal Wound Infection Rate (CABG): Postoperative Renal Failure (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery Process Yes EHR Yes Claims, EHR, CMS Yes of Thoracic Yes of Thoracic Process No 1

2 (CABG): Prolonged Intubation (CABG): Stroke (CABG): Surgical Re-Exploration Yes of Thoracic Yes of Thoracic Yes of Thoracic (CABG): Use of Internal Mammary Artery (IMA) in Patients with Isolated CABG Surgery Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%) Antiplatelet Therapy Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%) Documentation of Current Medications in the Medical Record Functional Status Assessments for Congestive Heart Failure Process No of Thoracic Process No American Heart Association Process No American Heart Association Process No EHR, Physician Consortium Process Yes Claims, EHR, Process Yes EHR Heart Failure (HF): Angiotensin- Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) Process No EHR, Physician Consortium Process No EHR, Physician Consortium HRS-12: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation HRS-3: Implantable Cardioverter- Defibrillator (ICD) Complications Rate Yes The Heart Rhythm Yes The Heart Rhythm 2

3 HRS-9: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision Hypertension: in Blood Pressure Ischemic Vascular Disease (IVD) All or None Measure (Optimal Control) Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet Medication Reconciliation Post- Discharge Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index Perioperative Anti-platelet Therapy for Patients Undergoing Carotid Endarterectomy Persistence of Beta-Blocker Treatment After a Heart Attack Body Mass Index (BMI) Screening and Follow-Up Plan Screening for High Blood Pressure and Follow-Up Documented Tobacco Use: Screening and Cessation Intervention Unhealthy Alcohol Use: Screening & Brief Counseling Yes The Heart Rhythm Yes EHR Yes Wisconsin Collaborative for Healthcare Quality Process Yes Claims, CMS Web Interface, Process Yes American College of Structure Yes American College of Process No Claims, for Vascular Process No Process No Claims, EHR, Physician Consortium Process No Physician Consortium 3

4 : Exposure Dose or Time Reported for Procedures Using Fluoroscopy : Stenosis Measurement in Carotid Imaging Reports Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications Operative Day #2) Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications Operative Day #2) Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) Who Die While in Hospital 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) Rate of Open Repair of Small or Moderate Abdominal Aortic Aneurysms (AAA) Where Patients Are Discharged Alive Rate of Open Repair of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications Operative Day #7) Rate of Postoperative Stroke or Death in Asymptomatic Patients Undergoing Carotid Artery Stenting (CAS) Rate of Postoperative Stroke or Death in Asymptomatic Patients Undergoing Carotid Endarterectomy (CEA) Process Yes Claims, American College of Process No Claims, American College of Yes for Vascular Yes for Vascular Yes for Vascular Yes for Vascular Yes for Vascular Yes for Vascular Yes for Vascular Yes for Vascular 4

5 Rate of Surgical Conversion from Lower Extremity Endovascular Revascularization Procedure Risk-Adjusted Operative Mortality for (CABG) Statin Therapy at Discharge after Lower Extremity Bypass (LEB) Statin Therapy for the Prevention and Treatment of Cardiovascular Disease Unplanned Hospital Readmission within 30 Days of Principal Procedure Unplanned Reoperation within the 30 Day Postoperative Period Use of High-Risk Medications in the Elderly Varicose Vein Treatment with Saphenous Ablation: Survey Yes Claims, of Interventional Yes of Thoracic Process No for Vascular Process No CMS Web Interface, Yes American College of Yes American College of Process Yes EHR, No of Interventional 5