IQSS1 Hypogonadism: Serum T, CBC, PSA, IPSS within 6 months of Rx Percentage of patients with a Effective Clinical Patients with documented new diagnosis of hypogonadism receiving androgen replacement therapy who have serum T, CBC, PSA, and IPSS documented within 6 months of first treatment Serum T, CBC, PSA, and IPSS within 6 months of first treatment Patients, regardless of age, with a new diagnosis of hypogonadism receiving first androgen replacement therapy IQSS2 Prostate Cancer: Newly diagnosed with documented T stage, PSA score, and Gleason score Percentage of newly diagnosed prostate cancer patients who prior to treatment have a documented evaluation of primary tumor (T) stage, PSA score, and Gleason score Effective Clinical All prostate cancer patients having a documented T stage, PSA score and Gleason score prior to treatment All newly diagnosed prostate cancer patients, regardless of age IQSS3 Prostate Cancer: Treatment Options Counseling Newly diagnosed prostate cancer patients receiving definitive local treatment (surgery, radiation, cryotherapy) with documented counseling of all treatment options (active surveillance, surgery, radiation) giver All patients receiving definitive treatment who have received verbal or written counseling, education materials, or a combination of these, detailing options available for treating and/or monitoring their prostate cancer before or on the earliest treatment date in the reporting following the earliest diagnosis date All newly diagnosed prostate cancer patients, regardless of age, receiving definitive treatment is Personalized and Aligned with Patient s Goals IQSS4 BPH: Anticholinergics Percentage of newly diagnosed BPH patients treated with anticholinergics where PVR is performed Effective Clinical Patients with documented PVR performed within 6 months after medication start date Newly diagnosed BPH patients, Medication regardless of age, treated with anticholinergics MUSIC11 Prostate Cancer: Follow- Up Testing for patients on active surveillance for at least 30 months Percentage of patients on active surveillance that have 2 tumor burden reassessments and 3 PSA tests in first 30 months since diagnosis Effective Clinical patients on active surveillance that have 2 tumor burden reassessments and 3 PSA tests in first 30 months since diagnosis patients aged 30 or older with new diagnosis of low and low-intermediate prostate cancer (Gleason 6 or low volume Gleason 3+4) Prostate cancer patients < 30 years of age; Patients that have had prior treatment for prostate cancer Appropriate use of 47 (NQF 0326) Plan Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan and Patients who have an advance All patients aged 65 years and care plan or surrogate decision older maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan is Personalized and Aligned with Patient s Goals
48 Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months Effective Clinical Patients who were assessed for All female patients aged 65 the presence or absence of years and older with a visit urinary incontinence within 12 months 50 Urinary Incontinence: Plan of for Urinary Incontinence in Women Aged 65 Years and Older 102 Prostate Cancer: (NQF 0389) Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months giver- Percentage of patients, Efficiency and regardless of age, with a Cost Reduction diagnosis of prostate cancer at low (or very low) risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of prostate cancer Patients who were assessed for the presence or absence of urinary incontinence within 12 months Patients who did not have a bone scan performed at any time since diagnosis of prostate cancer All female patients aged 65 years and older with a diagnosis of urinary incontinence All patients, regardless of age, with a diagnosis of prostate cancer at low (or very low) risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy Documentation of medical reason(s) for performing a bone scan (including documented pain, salvage therapy, other medical reason) Documentation of system reason(s) for performing a bone scan (including bone scan ordered by someone other than the reporting physician) Appropriate Use of 110 and (NQF 0041) Screening: Influenza Immunization Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization Patients who received an influenza immunization OR who reported previous receipt of an influenza immunization All patients aged 6 months and older seen for a visit during the Influenza immunization was not administered for reasons documented by clinician (e.g., patient allergy or other medical reasons, patient declined or other patient reasons, vaccine not available or other system reasons) 111 Pneumococcal (NQF 0043) Vaccination Status for Older Adults Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine 112 (NQF 2372) Breast Cancer Screening Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer Patients who have ever received a pneumococcal vaccination Patients 65 years of age and older with a visit during the Effective Clinical Women with one or more Women 51-74 years of age mammograms during the with a visit during the or the 15 months prior to the Women who had a bilateral mastectomy or who have a history of a bilateral mastectomy Hospice services used by patient any time during the Patient age 65 or older in care any time during the
113 Colorectal Cancer (NQF 0034) Screening Percentage of adults 50-75 years of age who had appropriate screening for colorectal cancer Effective Clinical Patients with one or more screenings for colorectal cancer Patients 50-75 years of age with a visit during the Patients with a diagnosis or past history of total colectomy or colorectal cancer. care year. Patient age 65 or older in care. 119 Diabetes: Medical (NQF 0062) Attention for Nephropathy The percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the Effective Clinical Patients with a screening for nephropathy or evidence of nephropathy during the Patients 18-75 years of age with diabetes with a visit care. 128 and (NQF 0421) Screening: Body Mass Index (BMI) Screening and Follow-Up Plan Percentage of patients aged 18 years and older with a BMI documented during the current previous twelve months AND with a BMI outside of normal parameters, a follow-up plan is documented during the previous twelve months of the current encounter Normal Parameters: Patients with a documented BMI during the encounter or during the previous twelve months, AND when the BMI is outside of normal parameters, a follow-up plan is documented during the previous twelve months of the current encounter All patients 18 and older on the date of the encounter with at least one eligible encounter Patients who are pregnant Patients receiving palliative care Patients who refuse measurement of height and/or weight or refuse follow-up Patients with a documented medical reason including but not limited to: Elderly Patients (65 or older) for whom weight reduction/weight gain would complicate other underlying health conditions such as illness or physical disability, mental illness, dementia, confusion, or nutritional deficiency Age 18 years and older BMI 18.5 and < 25 kg/m2 status 130 Documentation of Current Percentage of visits for patients (NQF 0419) Medications in the aged 18 years and older for Medical Record which the eligible professional or eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-thecounters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications name, dosage, frequency and route of administration Patient Safety Eligible professional or eligible All visits for patients aged 18 clinician attests to years and older documenting, updating or reviewing the patient's current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-thecounters, herbals and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosages, frequency and route of administration status Medication
131 Pain Assessment and (NQF 0420) Follow-Up Percentage of visits for patients aged 18 years and older with documentation of a pain assessment using a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present and Patient visits with a documented pain assessment using a standardized tool(s) AND documentation of a follow-up plan when pain is present All visits for patients aged 18 years and older Patients with severe mental and/or physical incapacity where the person is unable to express himself/herself in a manner understood by others. emergent situation where time is of the essence and to delay treatment would jeopardize the patient s health status. Patient's Experience of and Functional 143 Oncology: Medical and (NQF 0384) Radiation Pain Intensity Quantified Percentage of patient visits, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified giver- Patient visits in which pain intensity is quantified All patient visits, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy 144 Oncology: Medical and (NQF 0383) Radiation Plan of for Pain Percentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having pain with a documented plan of care to address pain giver- Patient visits that included a documented plan of care to address pain All visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having pain Patient Focused Episode of 226 and (NQF 0028) Screening: Tobacco Use: Screening and Cessation Intervention Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received tobacco cessation intervention if identified as a tobacco user 1: Patients who at least once within 24 months 2: Patients who received tobacco cessation intervention 3: Patients who at least once within 24 months AND who received tobacco cessation intervention if identified as a tobacco user 1: All patients aged 2: All patients aged who and identified as a tobacco user 3: All patients aged 1: Documentation screening for tobacco use (eg, limited life expectancy, other medical reason) 2: Documentation providing tobacco cessation intervention (eg, limited life expectancy, other medical reason) 3: Documentation screening for tobacco use OR for not providing tobacco cessation intervention for patients identified as tobacco users (eg, limited life expectancy, other medical reason) Prevention and Treatment of Opioid and Substance Use Disorders 3 No Traditional
236 Controlling Blood (NQF 0018) Pressure Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90mmHg) during the Effective Clinical Patients whose blood pressure at the most recent visit is adequately controlled (systolic blood pressure < 140 mmhg and diastolic blood pressure < 90 mmhg) during the Patients 18-85 years of age who had a diagnosis of essential hypertension within the first six months of the or any time prior to the measurement care year. Documentation of end stage renal disease (ESRD), dialysis, renal transplant before or or pregnancy during the. Intermediate Outcome Patients age 65 or older in care. 238 Use of -Risk Percentage of patients 65 years (NQF 0022) Medications in the Elderly of age and older who were ordered high-risk medications. Two rates are submitted. Patient Safety Numerator 1: Patients with an order for at least one high-risk medication during the Patients 65 years and older who had a visit during the Patients who use hospice services any time during the Medication 2 Yes Inverse 1) Percentage of patients who were ordered at least one highrisk medication. 2) Percentage of patients who were ordered at least two of the same high-risk medication Numerator 2: Patients with at least two orders for the same high-risk medication during the 317 and Screening: Screening for Blood Pressure and Follow-Up Documented 374 Closing the Referral Loop: Receipt of Specialist Report Percentage of patients aged 18 years and older seen during the reporting who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred and Patients who were screened for high blood pressure AND have a recommended followup plan documented, as indicated if the blood pressure is pre-hypertensive or hypertensive Number of patients with a referral, for which the referring provider received a report from the provider to whom the patient was referred All patients aged 18 years and older before the start of the with at least one eligible encounter Number of patients, regardless of age, who were referred by one provider to another provider, and who had a visit Patient has an active diagnosis of hypertension Patient refuses to participate (either BP measurement or follow-up) status. Communicatio n and 456 Proportion Not Admitted (NQF 0215) To Hospice Proportion of patients who died from cancer not admitted to hospice Effective Clinical Patients not admitted to hospice Patients who died from cancer Appropriate use of 1 No Inverse 462 Bone density evaluation for patients with prostate cancer and receiving androgen deprivation therapy Patients determined as having prostate cancer who are currently starting or undergoing androgen deprivation therapy (ADT), for an anticipated of 12 months or greater and who receive an initial bone density evaluation. The bone density evaluation must be prior to the start of ADT or within 3 months of the start of ADT. Effective Clinical Patients with a bone density evaluation within the two years prior to the start of or less than three months after the start of ADT treatment Male patients with a diagnosis of prostate cancer and an order for or who are actively undergoing ADT for a greater than or equal to 12 months with an office visit Patient refused recommendation for a bone density evaluation after the start of ADT therapy