QOPI5 Chemotherapy administered to patients with metastatic solid tumor with performance status of 3, 4, or undocumented (Lower Score - Better) Percentage of adult patients with metastatic solid tumors and performance status of 3, 4, or undocumented who receive chemotherapy (Lower score better) Diagnosis of Malignant neoplasm of placenta/trophoblastic neoplasm, testicular carcinoma Diagnosis codes (181.x (C58), 186.x (C62.9)) Patients 18 at cancer diagnosis 2 office visits in measurement period Solid tumor ICD code ((Intent not documented Stage IV at initial diagnosis or development of distant metastases = Yes) Intent = non-curative) Patient received chemotherapy for stage IV or distant metastatic disease) (Performance status documented within 2 weeks of most recent chemotherapy administration for distant metastatic disease = 3 or 4 Not documented) (Patient received chemotherapy for metastatic disease as part of IRB approved protocol = No Patient received chemotherapy for metastatic disease as part of IRB approved protocol = Unknown) QOPI11 Combination chemotherapy received within 4 months of diagnosis by women under 70 with AJCC stage IA (T1c) to III ER/PR negative breast cancer Percentage of adult women under 70 with a diagnosis of AJCC stage IA (T1c) to III ER/PR negative breast cancer, who receive combination chemotherapy within 4 months of diagnosis Transfer-in Status Reporting practice has/had primary responsibility for the initial course of the patient's medical oncology care M-Stage at breast cancer diagnosis = M1 Diagnosis of malignant phyllodes, cystosarcoma phyllodes, tubular carcinoma, mucinous carcinoma Patients 18-69 at diagnosis Breast cancer diagnosis 2 office visits in measurement period ((AJCC stage at breast cancer diagnosis = IIA -IIIC) (AJCC stage at breast cancer diagnosis = (IA and T-Stage at breast cancer diagnosis=t1c) or IB) Chemotherapy administered during initial treatment course (Breast cancer) = Multi-agent chemotherapy administered Date the chemotherapy was initiated (multi-agent) - Date of Diagnosis 124 days Alternative treatment according to clinical trial protocol information storage and retrieval system, without written permission by the Society. Updated: 06/26/2017 1
((Multi-agent Breast Chemotherapy administered = Chemotherapy NOT administered (Abstraction date diagnosis date < 124 days Deceased date diagnosis date < 124 days Date of first visit diagnosis date > 124 days) (Reason Multi-Agent Chemotherapy NOT Administered = Patient declined or Patient died or transferred or Contraindication or other clinical exclusion or Null)) (T-Stage at breast cancer diagnosis = T1c, T2-T4d and N-Stage at breast cancer diagnosis = N0) (N-Stage at breast cancer diagnosis = N1-N3c) (T1c and N1mi)) (ER status = ER negative and PR status = PR negative) QOPI15 GCSF administered to patients who received chemotherapy for metastatic cancer (Lower Score-Better) Percentage of adult patients with metastatic cancer who are administered chemotherapy and who receive a colony stimulating factor (Lower scorebetter) Diagnosis of malignant neoplasm of placenta/trophoblastic neoplasm, testicular carcinoma, leukemia, Hodgkin and non- Hodgkin s lymphoma Patients 18 at cancer diagnosis 2 office visits in ((Metastatic/advanced disease Chemotherapy administered) / Palliative intent chemotherapy administered) GCSF received = Yes information storage and retrieval system, without written permission by the Society. Updated: 06/26/2017 2
QPP 102 Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low (or very low) risk of recurrence receiving interstitial prostate brachytherapy, external beam radiotherapy to the prostate, radical prostatectomy, cryotherapy who did not have a bone scan performed at any time since diagnosis of prostate cancer Documentation of reason(s) for performing a bone scan (including documented pain, salvage therapy, other medical reasons, bone scan ordered by someone other than reporting physician) Diagnosis for prostate cancer (ICD-10- CM): C61 Patient encounter during the Low (very low) risk of recurrence = Yes Receiving interstitial prostate brachytherapy = Yes Receiving external beam radiotherapy to the prostate = Yes Receiving radical prostatectomy = Yes Receiving cryotherapy = Yes Bone scan not performed since time of diagnosis = Yes QPP 104 Prostate Cancer: Adjuvant Hormonal Therapy for High Risk or Very High Risk Prostate Cancer Percentage of patients, regardless of age, with a diagnosis of prostate cancer at high or very high risk of recurrence receiving external beam radiotherapy to the prostate who were prescribed adjuvant hormonal therapy (GnRH [gonadotropin-releasing hormone] agonist or antagonist) Diagnosis for metastatic cancer Documentation of medical reason(s) for not prescribing/administering adjuvant hormonal therapy (e.g., salvage therapy) Documentation of patient reason(s) for not prescribing/administering adjuvant hormonal therapy Diagnosis for prostate cancer (ICD-10- CM): C61 Patient encounter during the High or very high risk of recurrence = Yes Receiving external beam radiotherapy to the prostate = Yes Adjuvant hormonal therapy (GnRH gonadotropin-releasing hormone) agonist prescribed/administered = Yes Adjuvant hormonal therapy (GnRH gonadotropin-releasing hormone) antagonist prescribed/administered = Yes information storage and retrieval system, without written permission by the Society. Updated: 06/26/2017 3
QPP 130 Documentation of Current Medications in the Medical Record Percentage of visits for patients aged 18 years and older for which the eligible professional 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 must contain the medications' name, dosage, frequency and route of administration Patient Not Eligible: Eligible clinician attests to documenting in the medical record the patient is not eligible for a current list of medications being obtained, updated, or reviewed by the eligible clinician. Diagnosis of cancer Patients aged 18 years on date of encounter Patient encounter during the Eligible professional attests to documenting patient current medication in the medical record = Yes QPP 143 Oncology: Medical and 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 Diagnosis of cancer Each office visit during the (Receiving chemotherapy = Yes Receiving radiation therapy = Yes) Pain severity quantified; pain present Pain severity quantified; no pain present QPP 226 Preventive Care and 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 who received cessation counseling intervention if identified as a tobacco user Documentation of medical reason(s) for not screening for tobacco use (e.g., limited life expectancy, other medical reason) Patients 18 on date of encounter (Patient encounters during 2 Preventive encounter during 1) Tobacco use screening = Yes Tobacco cessation intervention = Yes Within 24 months of reported encounter = Yes information storage and retrieval system, without written permission by the Society. Updated: 06/26/2017 4
QPP 250 Radical Prostatectomy Pathology Reporting Percentage of radical prostatectomy pathology reports that include the pt category, the pn category, the Gleason score and a statement about margin status Specimen site other than anatomic location of prostate Documentation of medical reason(s) for not including pt category, pn category, Gleason score and statement about margin status in the pathology report (e.g., specimen originated from other malignant neoplasms, transurethral resections of the prostate (TURP), or secondary site prostatic carcinomas) Diagnosis for malignant neoplasm of prostate ICD 10-CM = C61) = Yes Patient procedure during performance period (CPT) = 88309 Pathology report documentation = pt category pn category Gleason score Margin status QPP 317 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated Active diagnosis of hypertension Documented reason for not screening or recommending a follow-up for high blood pressure. Patient refuses to participate (either BP measurement or follow-up) Patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient s health status. This may include but is not limited to severely elevated BP when immediate medical treatment is indicated Patients 18 Patient encounter during the Screened for high blood pressure = Yes (Blood pressure reading = Normal (Blood pressure is prehypertensive or hypertensive = Yes Recommended follow-up plan documented = Yes)) information storage and retrieval system, without written permission by the Society. Updated: 06/26/2017 5
QPP 449 HER2 Negative or Undocumented Breast Cancer Patients Spared Treatment with HER2- Targeted Therapies Proportion of female patients (aged 18 years and older) with breast cancer who are human epidermal growth factor receptor 2 (HER2)/neu negative who are not administered HER2-targeted therapies Patient transferred to practice after initiation of chemotherapy Female Patients 18 years on date of encounter Diagnosis of Breast Cancer HER-2/neu = Negative HER-2/neu = Undocumented HER-2/neu =Unknown HER2-targeted therapies not administered during the initial course of treatment = Yes QPP 450 Trastuzumab Received By Patients With AJCC Stage I (T1c) - III And HER2 Positive Breast Cancer Receiving Adjuvant Chemotherapy Proportion of female patients (aged 18 years and older) with AJCC stage I (T1c) III, human epidermal growth factor receptor 2 (HER2) positive breast cancer receiving adjuvant chemotherapy who are also receiving trastuzumab Patient transfer to practice after initiation of chemotherapy Patient has metastatic disease at diagnosis Reason for not administering Trastuzumab documented (e.g. patient declined, patient died, patient transferred, contraindication or other clinical exclusion, neoadjuvant chemotherapy or radiation NOT complete) Female Patients aged 18 years on date of encounter Diagnosis of breast cancer Patient encounter during performance period (CPT): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215 Breast Adjuvant Chemotherapy administered= Yes HER-2/neu = Positive AJCC stage at breast cancer diagnosis = II or III Trastuzumab administered within 12 months of diagnosis = Yes information storage and retrieval system, without written permission by the Society. Updated: 06/26/2017 6
QPP 451 KRAS Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody Therapy Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer who receive anti-epidermal growth factor receptor monoclonal antibody therapy for whom KRAS gene mutation testing was performed AJCC stage at breast cancer diagnosis = I (IA or IB) and T-Stage at breast cancer diagnosis does NOT equal = T1, T1a, T1b Patients aged 18 years on date of encounter Diagnosis of Initial colon or rectal cancer diagnosis Patient has metastatic disease at diagnosis Anti-EGFR monoclonal antibody therapy = Yes KRAS gene mutation testing performed before initiation of anti-egfr MoAb = Yes QPP 452 Patients with Metastatic Colorectal Cancer and KRAS Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer and KRAS gene mutation spared treatment with anti- EGFR monoclonal antibodies Patients aged 18 years on date of encounter Diagnosis of colon or rectal cancer Patient has metastatic disease at diagnosis KRAS gene mutation = Yes Anti-EGFR monoclonal antibody therapy (cetuximab or panitumumab) not administered = Yes information storage and retrieval system, without written permission by the Society. Updated: 06/26/2017 7
QPP 453 Proportion Receiving Chemotherapy in the Last 14 Days of Life (Lower score Better) Proportion of patients who died from cancer receiving chemotherapy in the last 14 days of life Diagnosis for cancer Deceased = Yes, patient is deceased as a consequence of his/her cancer Date of death - date of last chemo admin 14 days QPP 457 Proportion Admitted to Hospice for less than 3 days (Lower score Better) Proportion of patients who died from cancer, and admitted to hospice and spent less than 3 days there Diagnosis for cancer Hospice enrollment = Enrolled Deceased = Yes, patient is deceased as a consequence of his/her cancer Date of death - Hospice enrollment date < 3 days information storage and retrieval system, without written permission by the Society. Updated: 06/26/2017 8