Physician Consortium for Performance Improvement (PCPI) Performance Measure Status Report

Transcription

1 Acute Otitis Externa / Otitis Media with Effusion (8 measures) (AAO-HNS Foundation) AOE : Topical therapy AOE : Pain assessment AOE : Systemic antimicrobial therapy avoidance of inappropriate use OME : Diagnostic evaluation assessment of tympanic membrane mobility OME : Hearing test OME : Antihistamines or decongestants- avoidance of inappropriate use OME : Systemic antimicrobials avoidance of inappropriate use OME : Systemic corticosteroids avoidance of inappropriate use Adult Diabetes (12 measures) A1c management Lipid management Urine protein screening (2) Eye examination Foot examination Influenza immunization (2) Blood pressure management Aspirin use Smoking cessation (2) Anesthesiology and Critical Care (3 measures) (ASA) Prevention of ventilator-associated pneumonia head elevation Prevention of catheter-related bloodstream infections (CRBSI) central venous catheter (CVC) insertion protocol Perioperative temperature management G:\HQF\PCPI Measure Counts\PCPI_measure_counts_including NQF.xls Page 1 of 12

2 Asthma (2 measures) Asthma assessment Pharmacologic therapy Chronic Kidney Disease (6 measures) (RPA) Blood Pressure Management ACE Inhibitor (ACE) or Angiotensin Receptor Blocker (ARB) Therapy Laboratory Testing (Calcium, Phosphorus, PTH and Lipid Profile) Plan of Care - Anemia Influenza Immunization Referral for AV Fistula Chronic Obstructive Pulmonary Disease (12 measures) Spirometry evaluation Assessment of symptoms Smoking assessment Smoking cessation intervention Inhaled bronchodilator therapy Assessment of oxygen saturation Long term oxygen therapy Recommendation of influenza immunization Influenza immunization administered Assessment of pneumococcus immunization status Pneumococcus immunization administered Pulmonary rehabilitation: exercise training recommended G:\HQF\PCPI Measure Counts\PCPI_measure_counts_including NQF.xls Page 2 of 12

3 Chronic Stable Coronary Artery Disease (10 measures) (ACC / AHA) Blood pressure measurement Lipid profile Symptom and activity assessment Smoking cessation (2) Antiplatelet therapy Drug therapy for lowering LDL-cholesterol Beta-blocker therapy prior myocardial infarction (MI) ACE inhibitor or ARB therapy Screening for diabetes Community-acquired Bacterial Pneumonia (12 measures) Chest radiograph Assessment of co-morbid conditions Vital signs Assessment of oxygen saturation Assessment of mental status Assessment of hydration status Level of care rationale Empiric antibiotic Tobacco use assessment Tobacco cessation recommendation Assessment of influenza immunization status Assessment of pneumococcus immunization status G:\HQF\PCPI Measure Counts\PCPI_measure_counts_including NQF.xls Page 3 of 12

4 Emergency Medicine (9 measures) (ACEP) Electrocardiogram performed for non-traumatic chest pain (2yr) Aspirin at arrival for AMI (2 yr) Electrocardiogram performed for syncope (2 yr) Vital signs for community-acquired bacterial pneumonia (2 yr) Assessment for oxygen saturation for community-acquired bacterial pneumonia (2 yr) Assessment of mental status for community-acquired bacterial pneumonia (2 yr) Empiric antibiotic for community-acquired bacterial pneumonia (2 yr) Fibrinolytic therapy ordered within 20 minutes of ECG performed for AMI Care coordination for PCI End Stage Renal Disease (6 measures) (RPA) Influenza vaccination Vascular access patients receiving hemodialysis Vascular access patients receiving dialysis with a permanent catheter Plan of care for anemia Plan of care for inadequate hemodialysis Plan of care for inadequate peritoneal dialysis G:\HQF\PCPI Measure Counts\PCPI_measure_counts_including NQF.xls Page 4 of 12

5 Eye Care (13 measures) (AAO) Primary open-angle glaucoma: Optic nerve evaluation (2 yr) Primary open-angle glaucoma: Reduction of intraocular pressure by 15% or documentation of a plan of care Primary open-angle glaucoma: Counseling on glaucoma Age-related macular degeneration: Counseling on Antioxidant Supplements Age-related macular degeneration: Dilated macular examination (2 yr) Cataracts : Assessment of visual functional status Cataracts: Postoperative Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery Cataracts: Comprehensive Pre-operative Assessment for Cataract Surgery with Intraocular (IOL) Placement Diabetic retinopathy: Documentation of presence or absence of macular edema and level of severity of retinopathy (2 yr) Diabetic retinopathy: Communication with the physician managing ongoing diabetes care (2 yr) Gastroesophageal Reflux Disease (5 measures) (AGA Institute) Assessment for alarm symptoms Upper endoscopy for patients with alarm symptoms Biopsy for Barrett s esophagus Barium swallow inappropriate use Continuous medication therapy assessment of GERD symptoms G:\HQF\PCPI Measure Counts\PCPI_measure_counts_including NQF.xls Page 5 of 12

6 Geriatrics (9 measures) (AGS) Medication reconciliation (2 yr) Advance care plan Assessment of presence or absence of urinary incontinence in women aged 65 years and older (2 yr) Characterization of urinary incontinence in women aged 65 years and older (2 yr) Plan of care for urinary incontinence in women aged 65 years and older (2 yr) Urinary incontinence medication overuse in women aged 65 years and older Screening for future fall risk (2 yr) Risk Assessment for Falls Plan of Care for Falls Heart Failure (11 measures) (ACC / AHA) Left ventricular function assessment Weight measurement Blood pressure measurement Assessment of clinical symptoms of volume overload (excess) Assessment of activity level Assessment of clinical signs of volume overload (excess) Patient education Beta-blocker therapy ACE inhibitor or ARB therapy Warfarin therapy for patients with atrial fibrillation Laboratory tests G:\HQF\PCPI Measure Counts\PCPI_measure_counts_including NQF.xls Page 6 of 12

7 Hematology (4 measures) (ASH) Myelodysplastic syndrome (MDS) and acute leukemias: Baseline cytogenetic testing performed on bone marrow MDS : Documentation of iron stores in patients receiving erythropoietin therapy Multiple myeloma: Treatment with bisphosphonates Chronic lymphocytic leukemia: Baseline flow cytometry Hepatitis C (11 measures) (AGA Institute) Testing for chronic hepatitis C (HCV): confirmation of hepatitis C viremia HCV RNA testing before initiating treatment HCV genotype testing prior to treatment Consideration for antiviral therapy Combination antiviral therapy HCV RNA testing at week 12 of treatment Hepatitis A vaccination Hepatitis B vaccination Education regarding risk of alcohol consumption Counseling regarding use of contraception prior to antiviral treatment HCV RNA testing at week 24 of treatment (Quality Improvement Only) Hypertension (2 measures) (ACC / AHA) Blood pressure measurement Plan of care G:\HQF\PCPI Measure Counts\PCPI_measure_counts_including NQF.xls Page 7 of 12

8 Major Depressive Disorder (5 measures) Diagnostic evaluation Suicide assessment Severity classification Treatment: Psychotherapy, medication management, and/or electroconvulsive therapy Continuation of antidepressant medication Melanoma (4 measures) (AAD) Melanoma Follow-Up Measures Melanoma Continuity of Care Recall System Melanoma Coordination of Care Overutilization of Imaging Studies in Stage 0-1A Melanoma Oncology (10 measures) (ASTRO/ASCO) Cancer stage documented Hormonal therapy for stage IC through IIIC, ER/PR positive breast cancer Chemotherapy for Stage IIIA-Stage IIIC colon cancer patients Plan for chemotherapy documented Treatment summary documented and communicated Medical Oncology (Quality Improvement Only) Treatment summary communicated Radiation Oncology Normal tissue dose constraints specified Pain Intensity Quantified Plan of Care for Pain Pathology report (Quality Improvement Only) G:\HQF\PCPI Measure Counts\PCPI_measure_counts_including NQF.xls Page 8 of 12

9 Osteoarthritis (7 measures) (AAOS) Symptom and functional assessment Physical examination of the involved joint Assessment for use of anti-inflammatory or analgesic OTC medications Anti-inflammatory/analgesic therapy Non-steroidal anti-inflammatory drug (NSAID) risk assessment Gastrointestinal prophylaxis Therapeutic exercise for the involved joint Osteoporosis (6 measures) (AAFP / AAOS / AACE / ACR /TES) Communication with the physician managing on-going care post fracture (2 yr) Screening or therapy for women aged 65 years and older (2 yr) Management following fracture (2 yr) Pharmacological therapy (2 yr) Counseling for vitamin D, calcium intake and exercise Glucocorticosteroids and other secondary causes Outpatient Parenteral Antimicrobial Therapy (5 measures) (IDSA) Plan of care documentation at initial visit Maintenance visit history Maintenance visit physical examination Laboratory testing CBC Laboratory testing creatinine or GFR G:\HQF\PCPI Measure Counts\PCPI_measure_counts_including NQF.xls Page 9 of 12

10 Pathology (2 measures) (CAP) Breast cancer resection pathology reporting pt category and pn category with histologic grade Colorectal cancer resection pathology reporting pt category and pn category with histologic grade Pediatric Acute Gastroenteritis (4 measures) (AAP / AAFP) Documentation of hydration status Weight measurement Recommendation of appropriate oral rehydration solution Education Perioperative Care (6 measures) (ACS) Timing of prophylactic antibiotics ordering physician (2 yr) Timing of prophylactic antibiotics administering physician ( 2 yr) Selection of prophylactic antibiotic first or second generation cephalosporin (2 yr) Discontinuation of prophylactic antibiotics (non-cardiac procedures) (2 yr) Discontinuation of prophylactic antibiotics (cardiac procedures) (2 yr) Venous thromboembolism (VTE) prophylaxis (2 yr) Prenatal Testing (2 measures) Anti-D immune globulin Screening for human immunodeficiency virus G:\HQF\PCPI Measure Counts\PCPI_measure_counts_including NQF.xls Page 10 of 12

11 Preventive Care and Screening (6 measures) Colorectal cancer screening assessment: Colorectal cancer screening Adult influenza immunization: Influenza immunization received Problem drinking: Queried about and screened for problem drinking Screening mammography: Female patients who received a mammogram Tobacco use : Queried about tobacco use Tobacco use : Tobacco users who received cessation intervention Prostate Cancer (6 measures) (AUA) Initial evaluation Initial evaluation new diagnosis Overuse measure bone scan for staging low-risk patients Treatment options for patients with clinically localized disease Adjuvant hormonal therapy for high-risk patients Three-dimensional radiotherapy Radiology (8 measures) (ACR) Stenosis measurement in carotid imaging reports Breast Imaging Reporting and Data System (BI-RADS ) data collectoin Inappropriate use of Breast Imaging Reporting and Data System (BI-RADS ) category 3 in mammography screeing Communication of suspicious findings from the diagnostic mammogram to the practice managing ongoing care Communication of suspicious findings from the diagnostic mammogram to the patient Reminder system for mammograms CT radiation dose reduction Exposure time reported for procedures using fluoroscopy ; with changes ; with changes G:\HQF\PCPI Measure Counts\PCPI_measure_counts_including NQF.xls Page 11 of 12

12 Stroke and Stroke Rehabilitation (9 measures) (AAN / ACR) Deep vein thrombosis (DVT) prophylaxis for ischemic stroke and intracranial hemorrhage (2 yr) Discharged on antiplatelet therapy (2 yr) Anticoagulant therapy prescribed for atrial fibrillation (2 yr) Tissue plasminogen activator (t-pa) considered ( 2 yr) Screening for dysphagia (2 yr) Consideration of rehabilitation services (2 yr) Carotid imaging reports (2 yr) CT or MRI reports ( 2 yr) Avoidance of intravenous heparin (overuse measure) Notes: 1 The PCPI is currently evaluating the use of the phrases overuse, under use, appropriate and inappropriate in measure names. Measure names may be changed to ensure usage of these terms is consistent and precise. 2 Under development TOTAL Measure Sets: 31 TOTAL MEASURES: 213 G:\HQF\PCPI Measure Counts\PCPI_measure_counts_including NQF.xls Page 12 of 12